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Department of Nephrology, the First Affiliated Hospital Department of Nephrology, the First Affiliated Hospital Sun Yat-sun UniversitySun Yat-sun University
Qiongqiong Yang Qiongqiong Yang 杨琼琼杨琼琼
Glomerular disease
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Glomerular diseaseGlomerular disease
a group of diseases characterized by similar clincal manifestations :Proteinuria Hematuria Edema
Hypertension Etiology Pathogenesis Prognosis
: Different
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outlineoutline
Anatomy and functionGeneral pathogenesisClinical syndromes and presentationSpecific glomerular diseases
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Anatomy and functionAnatomy and function
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Anatomy
•Retroperitoneally posterior part of the abdomen
•Either side of the vertebral column
•Right kidney is one vertebral body lower than the left.
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Anatomy
Renal FunctionRenal FunctionRenal FunctionRenal Function
Remove wastesMaintain homeostasisSecrete EPO
Diagram of a bisected kidney
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Anatomy-nephron
•Functional unit of kidney
•Renal corpuscle( 肾小体 ): Glomerulus, Bowman’s Capsule
• Renal tubule (Proximal tubule, Loop of Henle, Distal tubule, Collecting duct)
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Three-dimensional schematic drawing of the glomerulus
Afferent arteriole
Efferent arteriole
Bowman’s Capsule
Basement membrane
Visceral Epithelium(Podocyte)
Parietal Epithelium
Capillary loops
Bowman’s Space
Endothelial cells
Stucture of renal glomerulus
Stucture of renal glomerulus
Mesangial matrix and cell
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Ultramicroscopic Stucture of glomerullar Capillaries
Filtration Mem
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Light micrograph of glomerulus
•Normal celluarity;
•Patent capillary lumens
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Glomerular AnatomyGlomerular Anatomy
Capillary Lumen
Endothelial cell
Glomerularbasementmembrane
Epithelialcell
Podocytes
Electron micrograph
Capillary Lumen毛细血管腔
Endothelial cell内皮细胞
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Ultrastructure of normal glomerular capillary
系膜细胞系膜基质
内皮细胞
上皮细胞足突
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General pathogenesisGeneral pathogenesis
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What causesglomerular disease ?
Most are of immunologic origin, and
caused by immune complexes !
• metabolic stress: DN
• mechanical stress:
• hypertension
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Antibody mediated GN -Antibody mediated GN - Circulating Immune complex Circulating Immune complex
Location: Mesangial and sub-endothelial
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Antibody mediated GN -Antibody mediated GN -
In-situ Immune complex In-situ Immune complex
Location: GBM sub-epithelial
• circulating auto antibodies with intrinsic autoantigens (component of normal parenchyma)
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Antibody mediated GN - In-situ Immune Antibody mediated GN - In-situ Immune complex (trapped Ag)complex (trapped Ag)
Location: GBM sub-epithelial
Extrinsic antigens planted within the glomerulus
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PathogenesisPathogenesis
In situ immune complex
Circulating immune complex
Activation of T lymphocytes
Acitvation of complements
cytokinesC5b-9 C5a,C3a
Epithelial, mesangial,
Endothelial cells
Macrophagepolynuclear leucocyte, platelets
polynuclear leucocyte, platelets
Mesangial cells
oxidative stress, protease, matrix accumulations
Glomerular Disease
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Characterizations of glomerular Characterizations of glomerular diseasedisease ??
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Glomerular Filtration BarrierGlomerular Filtration Barrier
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Glomerular Filtration Barrier InjuryGlomerular Filtration Barrier Injury
Fusion of foot process : ProteinuriaGBM Injury : Hematuria/ Proteinuria
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Characteristics of Glomerular Diseases
Parameter Glomerular Tubulointerstitial
Proteinuria
MW of Protein
Renal morphology
RBC Morphology
Massive>++
>1.5~2.0g/d
Large/Medium/Small
Symmetry
dysmorphic
Small amount<2+
<1.0g/d
Small
Asymmetry
normal
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HematuriaHematuria
Isomorphic nonglomerular erythrocytes. The arrows indicate the so-called crenated erythrocytes皱缩红细胞 , which are a frequent finding in nonglomerular hematuria.
Dysmorphic glomerular erythrocytes. The dysmorphism consists mainly in irregularities of the cell membrane. Inset, Acanthocytes 棘红细胞 with their typical ring-formed cell bodies with one or more blebs水泡 of different sizes and shapes.
Examination of the urine sediment by a phase constrast microscope
Dysmorphic glomerular erythrocytes>8000/ml,Acanthocytes>5%
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Classification of Glomerular Classification of Glomerular DiseaseDisease
EtiologyEtiology
PathologyPathology
ClinicalFeaturesClinical
Features
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Clinical syndromes and Clinical syndromes and presentationpresentation
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Clinical syndromes and Clinical syndromes and presentationpresentation
Latent GN
(asymptomatic urinary
abnormalities)
Nephrotic
syndrome
Acute GN RPGN Chronic GN
microscopic or
Macroscopic hematuria
Proteinuria
Dysmorphic
Glomerular
erythrocytes
Proteinuria>3.5g/d
Hypoalbuminemia
Hyperlipidemia
Edema
Proteinuria>3.5g/d
Hypoalbuminemia
Hyperlipidemia
Edema
Hematuria
Proteinuria
(1-3g/d)
ARF
Edema
Hypertension
Red cell casts
•Rapidly deterioration of renal function
•Hematuria, Proteinuria
• oliguria or anuria
Red cell casts
•With or without systemic symptom
•Hematuria, Proteinuria
•Hypertension
•Reduced GFR
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How are glomurular diseases diagnosed ?
Usually by history, physical findings,
Urinalysis and other laboratory data.
Occasionally a renal biopsy must be
performed !
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Renal Biopsy ProcessingRenal Biopsy Processing
• performed by nephrologists using real-time ultrasound guidance and disposable automated biopsy needles.
• 16-gauge needles
• lower pole of the kidney
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Renal Biopsy ProcessingRenal Biopsy Processing
• Ultrasound scan demonstrating the deepness of needle entering the lower pole of the left kidney (centimeter)
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Renal Biopsy ProcessingRenal Biopsy Processing
• Needle is guided into the probe pore
• passed under ultrasonic guidance to kidney capsule.
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Renal Biopsy ProcessingRenal Biopsy Processing
• The trigger mechanism is released with the pt stopping the breath
•firing the needle into the kidney
• Needle is immediately withdrawn
renal biopsy material
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PathologyPathology
PAS MASSON H&E PASM
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Pathological classification of GN
minimal change glomerulonephritis 轻微病变性肾小球肾炎
focal segmental lesions 局灶节段性病变 diffuse glomerulonephritis 弥漫性肾小球肾炎
membranous nephropathy 膜性肾病 proliferative glomerulonephritis 增生性肾炎
sclerosing glomerulonephritis 硬化性肾炎 unclassified glomerulonephritis 未分类性肾小球肾炎
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proliferative glomerulone-phritis 增生性肾炎 mesangial proliferative GN 系膜增生性肾小球肾
炎 endocapillary proliferative GN 毛细血管内增生性
肾小球肾炎 mesangial capillary GN 系膜毛细血管内增生性肾
小球肾炎 crecentic GN 新月体肾炎 Dense deposit glomerulonephritis
Pathological classification of GN
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Clinical syndromes of Clinical syndromes of glomerular diseasesglomerular diseases
Asymptomatic hematuria/ or proteinuria
Nephrotic syndrome Acute glomerular nephritis Rapidly progressive glomerular
nephritis Chronic glomerular nephritis
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Dysmorphic glomerular erythrocytes
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Asymptomatic hematuria/ or Asymptomatic hematuria/ or proteinuriaproteinuria
Latent nephritis
• Mild chronic GN or recovery phase of
acute GN
• Isolated microscopic hematuria
(Dysmorphic RBC)
• Isolated proteinuria
• No HBP, edema or Azotemia
• Treatment is similar to chronic GN
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CASE ICASE I CASE ICASE I
11 year-old male History: Intermittent hematuria x 1 year
Hx of recurrent pharyngitis Physical: tonsillitis
Urinalysis: 15 RBC/HPF
1 protein RBC casts
Lab Data: dysmorphic RBC
red blood cells per high-power field
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H&EH&E
Light microscopy: diffuse mesangial hypercellularity
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PASPAS
mesangial hypercellularity
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IgAIgA
Immunofluorescence microscopy: diffuse mesangial IgA
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Electron microscopy: mesangial electron-dense deposits.
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ThePatient Has
IgA nephropathy!
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IgA Nephropathy
• Most common GN• Mesangioproliferative or
other pathological types• Predominent mesangial IgA
deposit• Persistent or episode of
hematuria• Exacerbate on infection• 1/3 have elevated serum
IgA
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Clinical syndromes of Clinical syndromes of glomerular diseasesglomerular diseases
Asymptomatic hematuria/ or proteinuria
Nephrotic syndrome Acute glomerular nephritis Rapidly progressive glomerular
nephritis Chronic glomerular nephritis
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Nephrotic SyndromeNephrotic Syndrome
Insidious onset Manifestations
Proteinuria > 3.5g/d Hypoalbuminemia alb < 30 g/l Edema Hyperlipidemia
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Nephrotic syndrom-Nephrotic syndrom-etiology(1)etiology(1)
Primary Nephrotic syndrom
minimal change disease FSGS(focal segemental glomerular
disease) membranous nephropathy membranoproliferative GN IgAN
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Nephrotic syndrom-Nephrotic syndrom-etiology(2)etiology(2)
Secondary Nephrotic syndrom Autoimmunity:SLE,
Infection: Hepatitis B or C,HIV Tumor: solid carcinoma, lymphoma Metabolic: DM, Amyloidosis Drugs: NSAIDS
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Nephrotic syndrom-Nephrotic syndrom-epidemiologyepidemiology
Children Yong people Old people
Primary MCD FSGS,MsGN MN MPGNSecondary HSP SLE DN Hepatitis B HSP Tumor Inherited NS Hepatitis B MM , AL Henoch-Schönlein Nephritis Multiple myeloma , Amylosis
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14 year-old, male, high-school student History: No significant medical history
Fatigue x 3 weeks Edema x 1 week
Physical: Mild generalized edema Urinalysis: 4 protein
Many hyaline casts
Few granular casts
No RBCs or RBC casts Lab Data: proteinuria 4g/d , alb 20g/l,normal renal
function, Hepatitis (-), Auto-immunity Ab (-) Renal biopsy
CASE CASE IIII
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Electron Microscopy: effacement and fusion of foot processes
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The patient hasMinimal change
disease!
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Introduction
Incidence:
Etiology:
Clinical Features:
ClinicalCourse:
Loss of net negative charge on capillary basement membrane.
Nephrotic syndrome. Prominent proteinuria & edemaNo hypertension
Sensitive to steroid, relapse may occur.
80% of nephrotic syndrome in children
Minimal Change DiseaseMinimal Change Disease
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CASE IIICASE III
65 year-old, male, Smoke for 40 years History: Fatigue x 3 months
Cough and chest pain x 2 months Facial edema x 1 week Physical: edema, Urinalysis: protein ++++ Lab Data: proteinuria 8g/d , alb 24g/l, normal renal function,
Hepatitis (-), Auto-immunity Ab (-)
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Why is a thorough Clinical evaluation
important in patients with the nephrotic
syndrome !
Many such patients have
an occultmalignancy !
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CASE IIICASE III
Lung Carcinoma
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SilverSilver
PASPAS
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CASE IIICASE III
LM-PASM:”spikes” along the GBM
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CASE IIICASE III
IF: IgG deposition along GBM
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CASE IIICASE III
EM: subepithelial electron dense material
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It’s Clearly a case Of carcinoma related
Membranous nephropathy !
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CASE II-MNCASE II-MN
Commonly occurred in middle&old-aged peopleEtiology : Primary Secondary : Tumor-related,
Hepatitis B related , Drugs - related Presentation: HT & Renal failure, Thrombosis
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Introduction
Membranous Nephropathy
Incidence:
Etiology:
Path:
ClinicalCourse:
Immune complex disease. May associated with carcinomas, infections, drugs, and heavy metals.
Some adults develop ESRD.
Diffuse, uniform basement membrane thickening with subepithelial projections (“spikes”).
Commonly occurred in middle&old-aged people
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How to treat the Nephrotic
Syndrome?
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Pathogenesis/Complication
Liver
Edema
Hypoalbuminemia
Glom inflammation
Proteinuria ↑
Permeability↑
Lipoprotein Synthesis↑
Blood Lipid↑
Primary Secondary Causes
Blood volume↓
Thrombosis
CV disease↑
ARF
Infection
vitD deficiency
Protein malnutrition
Development↓
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Treatment of NS
Liver
Edema
Hypoalbuminemia
Glom inflammation
Proteinuria ↑
Permeability↑
Lipoprotein Synthesis↑
Blood Lipid↑
Primary Secondary Causes
Causative TherapySteroid/CTX/CsAACEI/ARB
Diuretics
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Liver
Edema
Hypoalbuminemia
Glom inflammation
Proteinuria ↑
Permeability↑
Lipoprotein Synthesis↑
Blood Lipid↑
Primary Secondary Causes
Treatment of Complication
Blood volume↓
Thrombosis
CV disease↑
ARF
Infection
Antithrombotic
Anti-infection
Diuretics/Dialysis
Statins
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0.25mg/kg.d
Slow the speed of tapering
1mg/kg.d×8w
0.5mg/kg.d
Taper 5mg per 1-2week
How to use glucosteroids(1)
Maintenance for 1 year
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0.25mg/kg.d
Slow the speed of tapering
1mg/kg.d×8w
0.5mg/kg.d
Taper 5mg per week
How to use glucosteroids(1)
Maintenance for 1 year
Sufficient initial dose
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0.25mg/kg.d
Slow the speed of tapering
1mg/kg.d×8w
0.5mg/kg.d
Taper 5mg per week
How to use glucosteroids(3)
Maintenance for 1 year
Sufficient initial dose
Slow tapering
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0.25mg/kg.d
Slow the speed of tapering
1mg/kg.d×8w
0.5mg/kg.d
Taper 5mg per week
How to use glucosteroids
Maintenance for 1 year
Sufficient initial dose
Slow tapering
Long maintenance
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Clinical syndromes of Clinical syndromes of glomerular diseasesglomerular diseases
Asymptomatic hematuria/ or proteinuria
Nephrotic syndromeAcute glomerular nephritisRapidly progressive glomerular
nephritis Chronic glomerular nephritis
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急性肾小球肾炎 急性肾小球肾炎 Acute GNAcute GN
History of streptococcus infection 2 weeks ago
Acute onset Prominent hematuria and RBC castsARF & HTLow C3 , for 8weeksESR increased , Anti-DNAseB(+)
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急性肾小球肾炎 急性肾小球肾炎 Acute GNAcute GN
Endocapillary proliferation:A diffuse proliferative and exudative glomerulonephritis :infiltration of the glomerular tuft
by neutrophils and monocyte
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cute GNcute GN
Treatment : eliminating the streptococcal infection with antibiotics; supportive therapy
Prognosis: Spontaneous resolution(for children within 6-8 wks). Excellent prognosis, and rarely causes ESRD.
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Clinical syndromes of Clinical syndromes of glomerular diseasesglomerular diseases
Asymptomatic hematuria/ or proteinuria
Nephrotic syndromeAcute glomerular nephritisRapidly progressive glomerular
nephritis Chronic glomerular nephritis
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Rapid progressive GN
• Similar to acute GN on onset• Rapid deterioration of renal
function• Cr↑ , Oliguria and obvious
macroscopic hematuria• Crescent formation>50%• Need aggressive
therapy(Large dose of steroid
pulse therapy + CTX ;Plasmaphoresis)
• Prognosis: poor, most require
dialysis.
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Rapid progressive GN
Crescent
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Idiopathic crescentic GN(RPGN) : Type I : with linear deposits of Ig anti -
GBM antibody+ Type II: with granular deposits of Ig
immune complex-mediated Type III: with few or no immune deposits
of Ig Pauci-immne ,ANCA+ Type IV: anti - GBM antibody + &
ANCA+ Type V: Pauci-immne , ANCA-
Rapid progressive GN
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Clinical syndromes of Clinical syndromes of glomerular diseasesglomerular diseases
Asymptomatic hematuria/ or proteinuria
Nephrotic syndromeAcute glomerular nephritisRapidly progressive glomerular
nephritis Chronic glomerular nephritis
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Chronic glomerulonephritis
• Clinical presentations:
Proteinuria(<3.5g/d);Hematuria;
Hypertension;Edema;Azotema(BUN/Cr↑)
• Pathological manifestations of all of major glomerulopathies.
• Exclusion of secondary cause :SLE etc.
• To correct the reversible factors: hypertension, infection, drug toxicity
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Treatment of Chronic GN
• Reduce proteinuria• Control hypertension
• ACE-I or AT II receptor blocker/ antagonist (ARB): reducing proteinuria in addition to lowing of blood pressure
• Low protein diet for azotemia• Avoid nephrotoxic agents• Anti-platelet aggregation
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TAKE HOME MESSAGE TAKE HOME MESSAGE !!
One important clinic syndrome of glomerular disease: Nephrotic syndrome !
Diagnosis is based on thorough clinic evaluation !
Renal biopsy is critical for diagnosis !