Glomerulonephritis

Management of Glomerulonephritis

Aims of Management

Treatment goals depend on the type, severity, and underlying cause of GN. 

General goals include: 

• preserving kidney function, 
• managing symptoms, 
• treating the underlying cause if possible, and 
• preventing complications.

General Supportive Measures:

Blood Pressure Control: Crucial for slowing progression. Often requires multiple medications. ACE inhibitors (ACEi) or Angiotensin II Receptor Blockers (ARBs) are often preferred as they can also reduce proteinuria. Target BP is usually <130/80 mmHg, potentially lower if proteinuria is significant.

Maintain Healthy Weight: Through appropriate diet and exercise (as tolerated).

Fluid Management:

• Sodium and Water Restriction: To control edema and hypertension. Fluid intake may be limited based on urine output and fluid status.
• Diuretics: Loop diuretics (e.g., furosemide) are commonly used to manage fluid overload and edema. Thiazides may be added if needed.

Dietary Modifications:

• Protein Restriction: May be recommended in CKD to reduce workload on kidneys, but needs careful balancing to avoid malnutrition. Limit usually guided by GFR level. Less restriction or even normal intake may be needed in nephrotic syndrome to compensate for losses, requires careful monitoring.
• Potassium, Phosphorus, Magnesium Restriction: Necessary if levels are elevated, common in advanced CKD. Requires avoiding certain foods and potentially using phosphate binders.
• Calcium Supplements: May be needed if dietary intake is low or due to CKD mineral bone disease, often alongside Vitamin D analogues.

Specific Treatments (Based on GN type/cause):

Treating Underlying Infections: Antibiotics for bacterial infections (e.g., penicillin for post-streptococcal GN prevention in outbreaks or treating active infection; treatment for endocarditis). Antivirals for Hepatitis B/C or HIV.

Plasma Exchange (Plasmapheresis): Removes harmful antibodies from the blood. Used in conditions like Anti-GBM disease and severe ANCA-associated vasculitis.

Immunosuppression: Used for many primary immune-mediated GN and secondary forms like lupus nephritis or vasculitis. Aims to reduce inflammation and harmful immune responses.

• Corticosteroids (e.g., Prednisone): Mainstay for many types.
• Cytotoxic Agents (e.g., Cyclophosphamide, Mycophenolate Mofetil [MMF], Azathioprine): Used for more severe or resistant cases.
• Calcineurin Inhibitors (e.g., Tacrolimus, Cyclosporine): Used for some types like Minimal Change, FSGS, Membranous.
• Biologic Agents (e.g., Rituximab – targets B cells): Increasingly used for ANCA vasculitis, lupus nephritis, some other types.
  (Immunosuppression carries risks of infection, malignancy, and other side effects, requiring careful monitoring).

Management of Complications:

• Dialysis (Hemodialysis or Peritoneal Dialysis): Required for acute kidney injury with severe complications (fluid overload, hyperkalemia, acidosis, uremia) or for End-Stage Renal Disease (ESRD) when GFR is very low (<15 mL/min).
• Anemia Management: Erythropoiesis-stimulating agents (ESAs) and iron supplementation.
• Mineral and Bone Disorder Management: Phosphate binders, Vitamin D analogues, calcimimetics.
• Hyperlipidemia Management: Statins may be used, especially in nephrotic syndrome.

Lifestyle Changes & Patient Education:

• Adherence to medications, diet, and fluid restrictions.
• Regular monitoring of BP, weight, and symptoms.
• Smoking cessation.
• Avoidance of nephrotoxic substances (e.g., NSAIDs, certain contrast dyes).
• Understanding the disease, treatment plan, and potential complications.

Physiotherapy and Supportive Care:

• Endurance Exercise: As tolerated (walking, swimming, cycling) can improve cardiovascular health, circulation, and well-being. Helps kidneys discharge waste and toxins by improving overall circulation.
• Breathing Exercises: Pursed-lip breathing and diaphragmatic breathing can help manage shortness of breath associated with fluid overload or anxiety.
• Edema Management: Elevation of edematous limbs, gentle range-of-motion exercises. Lymphatic massage may be considered for persistent edema, but primary treatment is addressing the underlying fluid overload medically.
• Energy Conservation Techniques: Pacing activities, rest periods, especially if fatigued due to anemia or uremia.

Nursing Management

Goals of Nursing Care:

• Maintain fluid and electrolyte balance.
• Achieve and maintain target blood pressure.
• Alleviate pain and discomfort.
• Maintain effective breathing pattern and gas exchange.
• Prevent skin breakdown.
• Prevent infection.
• Maintain adequate nutritional status.
• Patient verbalizes understanding of disease and treatment plan.
• Patient copes effectively with diagnosis and lifestyle changes.

Assessment:

• Vital Signs: Frequent BP monitoring, heart rate, respiratory rate, temperature.
• Fluid Balance: Strict intake and output monitoring, daily weights (most sensitive indicator of fluid status), assessment for edema (location, severity, pitting), jugular venous distension, lung sounds.
• Symptoms: Assess for changes in urine (color, amount, foaminess), fatigue, shortness of breath, pain, nausea/vomiting.
• Skin Integrity: Assess edematous areas for breakdown.
• Neurological Status: Assess for headache, visual changes, confusion (signs of severe HTN or uremia).
• Psychosocial Assessment: Coping mechanisms, anxiety, knowledge about the disease.
• Monitor Lab Results: BUN, Creatinine, electrolytes, CBC, albumin, etc.

Nursing Diagnoses :

• Excess Fluid Volume related to compromised regulatory mechanisms (renal failure) and sodium/water retention as evidenced by edema, weight gain, hypertension, abnormal lung sounds, decreased urine output.
• Acute Pain related to inflammation of the renal cortex/capsular distension as evidenced by patient report of flank pain, facial grimacing.
• Ineffective Breathing Pattern or Impaired Gas Exchange related to fluid overload (pulmonary edema) as evidenced by dyspnea, tachypnea, abnormal breath sounds, low oxygen saturation.
• Risk for Impaired Skin Integrity related to edema.
• Decreased Activity tolerance related to fatigue (anemia, uremia) and fluid overload.
• Inadequate nutritional intake related to anorexia, nausea, dietary restrictions.
• Risk for Infection related to altered immune status or immunosuppressive therapy.
• Disrupted Body Image related to edema, presence of dialysis access, or chronic illness.
• Excessive anxiety related to diagnosis, prognosis, and treatment complexity.
• Deficient Knowledge related to disease process, dietary restrictions, medications, and self-care management.

Interventions:

• Fluid Management: Administer diuretics as ordered, enforce fluid/sodium restrictions accurately, monitor I&O and daily weights meticulously, elevate edematous extremities, assist with frequent position changes to mobilize fluid and prevent skin breakdown.
• Blood Pressure Management: Administer antihypertensives as ordered, monitor BP closely (before/after meds, postural checks if indicated).
• Pain Management: Assess pain thoroughly (onset, location, quality, severity), provide comfort measures (positioning, quiet environment), administer analgesics as ordered (use caution with NSAIDs), explore relaxation techniques/diversion therapy.
• Respiratory Support: Elevate head of bed (Semi-Fowler’s or High-Fowler’s position) to ease breathing, monitor respiratory status (rate, depth, effort, O2 saturation), administer oxygen as needed, encourage deep breathing/coughing exercises (if appropriate, not overly strenuous).
• Nutritional Support: Collaborate with dietitian, provide prescribed diet, monitor intake, manage nausea/vomiting (antiemetics as ordered), provide oral care.
• Skin Care: Gentle cleansing, moisturizing, use pressure-relieving surfaces if bed-bound, handle edematous skin carefully.
• Activity Management: Encourage rest periods, assist with ADLs as needed, gradually increase activity as tolerated, plan activities to conserve energy.
• Infection Prevention: Monitor for signs of infection (fever, increased WBC, site-specific signs), use aseptic technique, educate patient on hand hygiene and avoiding sick contacts (especially if immunosuppressed).
• Medication Administration: Administer all medications accurately and on time (diuretics, antihypertensives, immunosuppressants, antibiotics, phosphate binders, etc.), monitor for therapeutic effects and side effects. Administer albumin infusions as ordered (helps shift fluid from interstitial space to intravascular space, often followed by diuretics).
• Psychosocial Support: Provide emotional support, encourage verbalization of feelings, involve family, provide clear explanations, refer to support groups or counseling if needed.
• Patient Education: Teach about the disease, medications (purpose, dose, side effects), dietary/fluid restrictions, monitoring (BP, weight, symptoms), when to seek medical attention, importance of follow-up.
• Preparation for Procedures: Educate and prepare patient for kidney biopsy, dialysis initiation if necessary.