FOLLOW-UP CARE FOR GLOMERULONEPHRITIS

Dyad Three (3)
Byron Webb A. Romero
Von Deneb H. Vitto
Raymond C. Ursal

DATA ENTRY FOR FOLLOW UP CARE: GN

Patients with GN should undergo or have follow up course monitoring of laboratory studies which include serum albumin as well as serum creatinine. In a study conducted by Sesso and Pinto (2005) which includes patients from GN outbreak in Nova Serrana, it shows that patients who have GN have been found to have presenting hypertension, decreasing renal function as evidenced by a createnine clearance lower than 80 mL/min and increased microalbuminemia. This would then imply that during the follow up phase of patients with GN, monitoring of blood pressure is of basic importance, and findings must be referred appropriately. Routine blood urea nitrogen and creatinine test must also be performed to monitor renal functioning and serum albumin must also be considered as a routine laboratory workup to be done so as to prevent complications of GN. These laboratory findings may suggest in leading for the utilization of renal biopsy as a follow up in checking the prognosis of GN clients.

The research conducted by Sesso and Pinto (2005) used a prospective study in re-examining 56 of the 135 identified cases of GN in 1998. At the follow-up examination, arterial hypertension was found in 30% of the subjects, reduced creatinine clearance (<80 ml/min) in 49% and increased microalbuminuria (>20 µg/min) in 22%. Comparing the data gathered in 2005 from the data 3 years prior, the number of cases with creatinine clearance lower than 80 ml/min increased from 20 to 26. Increased microalbuminuria and/or reduced creatinine clearance were detected in 57% of the subjects. During the researcher’s visit in 2003, recently voided urine samples were collected for sediment examination and a protein dipstick test; blood samples were drawn usually after fasting, interim histories were obtained and physical examinations were performed. Blood samples were examined for serum creatinine and glomerular filtration rate (GFR) was considered reduced when creatinine clearance was lower than 80 ml/min. Samples from 24-hour urine collection were tested for microalbuminuria by radioimmunoassay. 11 of the 135 confirmed cases of PSGN (post streptococcal glomerulonephritis) seen in 1998 had already died during the follow-up. Only 56 subjects were re-evaluated in the present study after a mean time of 65 months. The 56 cases assessed were among the 67 patients evaluated earlier in 2000.

Comparing the results of this evaluation with that of the data gathered at 2 years, patients found to be hypertensive and has microalbuminuria decreased, but the percentage of cases with reduced renal function increased. This increase suggests that a progressive loss of renal function may be occurring in some patients. Hypertension and diabetes among the elderly is also suggestive of lower creatinine clearance which could negatively affect their prognosis. A recommendation for a longer follow-up of this study will be important in assessing possibility of progressive reduction of renal function which cannot be ascertained through the limited time provided in this study.

Reference:

Sesso, R. and Pinto, S.W.L. (2005). Five-year follow-up of patients with epidemic glomerulonephritis due to Streptococcus zooepidemicus. Nephrology Dialysis Transplantation 2005 20(9):1808-1812. Retrieved July 5, 2009, from: http://ndt.oxfordjournals.org/cgi/content/full/20/9/1808?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=meta-analysis+follow-up+in+glomerulonephritis&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT.

Response: FOLLOW-UP GUIDELINES AND MORTALITY
By: D2- Gil legarda and Joanalyn Balino

Focal and Segmental Glomerulosclerosis: Definition and Relevance of a Partial Remission
Ste´phan Troyanov, Catherine A. Wall, Judith A. Miller, James W. Scholey, and
Daniel C. Cattran, for the Toronto Glomerulonephritis Registry Group



This study made by Trayanov, S. et al. aimed to determine whether Patial remission (PR) in proteinuria was an end point predictive on the rate of progression of renal disease and survival from renal failure. This study compares the rate of renal function decline, relapse, renal failure, and treatment effects among patients with a partial remission (PR), complete remission (CR), and no remission (NR). And also, it addresses the long-term implications of a partial remission in nephrotic focal and segmental glomerulosclerosis (FSGS) patients.There were 281 patients who were nephrotic at some time during their follow-up included in the study. These patients have a median follow-up of 5 yrs. 124 patients of the group were lost to follow-up. The Exclusion criteria include: (1) patients who were younger than 18 years old; (2) those with probable secondary FSGS; (3) with neither proteinuria nor weight measured; (4)with less than 12 months; (5) follow-up never nephritic.



The rate of renal function decline was slower with a lower proteinuria P = 0.01. No remission (NR) group, the patients who had a
50% reduction in proteinuria but did not reach 3.5 g/d did not have a better renal survival or slower rate of progression compared with the rest of the NR group. BMI was independently associated with a better renal survival and a slower rate of renal function decline. The nadir in proteinuria in remission and male gender were significantly associated with the risk of relapse. Patients who had a PR and relapsed had an overall rate of renal function decline significantly worse than those who did not but patients who had a PR and relapsed still had a better renal survival than the no remission (NR) group There is a slower progression and a better renal survival with the use of ACEi or ARB therapy.There is more clinically meaningful benefit is achieved when the 50% reduction in proteinuria is combined with a nadir less than 3.5 g/d.


In addition to a complete remission (CR), achieving a patial remission PR was independently associated with a slower rate of renal function decline and a reduced risk for renal failure. Those who relapsed from a partial remission PR had a significantly faster rate of renal function decline and lower renal survival than those who never relapsed. This emphasizes the importance of maintaining non–nephrotic-range proteinuria.. It raises the issue of maintenance therapy rather than targeting complete withdrawal of treatment after a short exposure period, particularly when the remission is only partial. This study provides evidences that partial remission ( PR) is a valid and important therapeutic goal for clinician to target because it is strongly correlated with both a reduction in the rate of renal disease progression and a better renal survival.

Reference
Trayanov, S. et al.(2005). Focal and Segmental Glomerulosclerosis: Definition and Relevance of a Partial Remission. J Am Soc Nephrol 16: 1061-1068. Retrieved July 6, 2009 from
http://jasn.asnjournals.org/cgi/reprint/16/4/1061?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=0&minscore=5000&resourcetype=HWCIT

Dyad 6 guomanman and chenya

Further Inpatient Care

* Patients should be monitored closely for steroid-induced diabetes, electrolyte abnormalities, abnormal gas exchange, and opportunistic infections.

Further Outpatient Care

* Renal function should be monitored closely.
* Hypertension should be treated aggressively.
* Patients should be monitored closely for steroid-induced diabetes and opportunistic infections.

Deterrence/Prevention

* No clear risk factors are associated with development of DPGN; thus, no known preventive methods can be advocated.

Complications

* End-stage renal disease
* Complications of steroid or cytotoxic therapy are discussed under Medication. The commonly encountered complications include diabetes, opportunistic infections, and infertility.
* Complications of the specific diseases are discussed in other articles.

Prognosis

* Evidence of glomerulosclerosis, fibrous crescents, tubular atrophy, and, particularly, interstitial fibrosis using light microscopy indicates advanced disease and a poor prognosis.
* Being a male is a higher risk factor for a bad prognosis.1 Other risk factors associated with a bad prognosis include heavy proteinuria, hypertension, interstitial fibrosis, oliguria, and azotemia at presentation.
* Renal survival is best with IgA and worse with anti-GBM disease. In some series, the rate of progression to ESRD in class IV lupus was 50% during a 2-year follow-up.11
* Overall, about 50% of patients with DPGN require dialysis within 6-12 months after presentation.

Patient Education

* Educate patients on the disease process, renal prognosis, complications of therapy, and importance of adhering to the treatment plan. The importance of keeping appointments must be emphasized.
* For those with advanced renal failure, options for renal replacement therapy (ie, hemodialysis, peritoneal dialysis, transplantation) should be fully discussed.
* For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Blood in the Urine.
* For further information, see Mayo Clinic - Kidney Transplant.

Miscellaneous
Medicolegal Pitfalls

* Delay in diagnosis and treatment may result in rapid progression to ESRD.
* Inadequate monitoring of cytotoxic therapy may result in life threatening complications.

Special Concerns

* Infertility may result from use of cyclophosphamide; thus, informed consent should be obtained before instituting this form of therapy.

http://emedicine.medscape.com/article/239646-followup