Suspected Glomerular Disease
Proteinuria, hematuria, or declining kidney function
All Pathways
NephrologyDiagnostic
Glomerulonephritis Evaluation (KDIGO 2021)
Glomerulonephritis Evaluation (KDIGO 2021): Suspected Glomerular Disease → Initial Laboratory Evaluation → Clinical Syndrome Classification → Nephrotic ...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Initial Laboratory Evaluation
Comprehensive workup for suspected GN
- Urinalysis with microscopy (dysmorphic RBCs, RBC casts)
- Spot urine protein/creatinine ratio (UPCR)
- Serum creatinine, eGFR
- Serum albumin
- Complete metabolic panel
- CBC with differential
03Decision Clinical Syndrome Classification
Pattern of presentation guides workup
- Nephrotic: Proteinuria >3.5g/day, hypoalbuminemia, edema, hyperlipidemia
- Nephritic: Hematuria (RBC casts), HTN, oliguria, modest proteinuria, AKI
- Mixed: Features of both
- Asymptomatic: Isolated hematuria or proteinuria
04Action Nephrotic Syndrome Workup
Additional testing for nephrotic presentation
- Anti-PLA2R antibody (membranous nephropathy)
- Hepatitis B and C serologies
- HIV
- ANA (lupus nephritis if positive)
- Serum and urine protein electrophoresis (SPEP/UPEP)
- Fasting lipids
- Consider: Light chains, HbA1c
05Action Renal Imaging
Assess kidney size and rule out obstruction
- Renal ultrasound: Size, echogenicity, obstruction
- Normal/large kidneys: More likely acute/reversible
- Small echogenic kidneys: Chronic damage, biopsy may not help
- Single kidney or other contraindications to biopsy
06Decision Kidney Biopsy Indicated?
Consider indications and contraindications
- Indications:
- - Unexplained AKI with active sediment
- - Nephrotic syndrome in adults (except DM >10yr + retinopathy)
- - Nephritic syndrome with systemic features
- - Rapidly progressive GN (RPGN)
- Contraindications: Uncontrolled HTN, bleeding diathesis, single kidney (relative)
07Action Empiric Management
If biopsy not performed/pending
- ACEi/ARB for proteinuria (max tolerated dose)
- SGLT2i if eGFR allows
- Blood pressure control <130/80
- Edema management (diuretics)
- Statin for hyperlipidemia
- DVT prophylaxis if severe nephrotic
08Outcome Remission/Stable
Monitor for relapse, continue nephroprotection
09Action Proceed with Kidney Biopsy
Gold standard for GN diagnosis
- Pre-biopsy: Check BP, coagulation, consent
- Light microscopy, immunofluorescence, electron microscopy
- Provides: Diagnosis, activity vs chronicity, prognosis
- Post-biopsy: Observe 6-24h, check Hgb
10Action Interpret Biopsy Results
Common diagnoses by pattern
- Nephrotic pattern: MCD, FSGS, Membranous, Diabetic
- Nephritic pattern: IgAN, Lupus nephritis, ANCA GN, Anti-GBM
- MPGN pattern: Consider cryoglobulinemia, C3 glomerulopathy
- Activity index guides intensity of treatment
- Chronicity index indicates irreversible damage
11Action Disease-Specific Treatment
Tailored to biopsy diagnosis
- MCD: High-dose steroids (responds well)
- FSGS: Steroids, calcineurin inhibitors if refractory
- Membranous: Rituximab or CNI if anti-PLA2R+
- IgAN: Optimize RAAS blockade, consider steroids if high risk
- Lupus nephritis: MMF or cyclophosphamide + steroids
- ANCA vasculitis: Rituximab or cyclophosphamide + steroids
- Path rejoins step 08Shared downstream outcome
12Outcome Refractory/Progressive
Consider alternative agents, clinical trial, transplant evaluation
13Warning RPGN Suspected?
Rapidly progressive GN is an emergency
- Features: AKI over days-weeks, active sediment, HTN
- Causes: ANCA vasculitis, anti-GBM, lupus, PIGN
- Consider empiric steroids while awaiting biopsy
- Urgent nephrology consultation
- May need plasma exchange (anti-GBM, severe ANCA)
- Path rejoins step 09Shared downstream outcome
14Action Nephritic Syndrome Workup
Additional testing for nephritic presentation
- Complement levels (C3, C4)
- ANCA (MPO, PR3)
- Anti-GBM antibody
- ANA, anti-dsDNA
- ASO titer (post-streptococcal)
- Blood cultures if concern for endocarditis
- Cryoglobulins
- Path rejoins step 05Shared downstream outcome
Guideline Source
KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Kidney biopsy is often required for definitive diagnosis
- Treatment depends on specific histopathology
- Does not cover all specific GN subtypes in detail
- Immunosuppression regimens vary by center
Applicable Regions
EUUSglobal
global: KDIGO 2021 is international guideline; specific treatments may vary
Version 1Next review: 2027-01-01
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eGFR (CKD-EPI 2021)
Estimated glomerular filtration rate using CKD-EPI 2021 equation (race-free)
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Related Resources
Frequently Asked Questions
What is the Glomerulonephritis Evaluation (KDIGO 2021)?
The Glomerulonephritis Evaluation (KDIGO 2021) is a diagnostic clinical algorithm for Nephrology. It provides a structured decision tree to guide clinical decision-making, based on KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases.
What guideline is the Glomerulonephritis Evaluation (KDIGO 2021) based on?
This algorithm is based on KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases (DOI: 10.1016/j.kint.2021.05.021).
What are the limitations of the Glomerulonephritis Evaluation (KDIGO 2021)?
Known limitations include: Kidney biopsy is often required for definitive diagnosis; Treatment depends on specific histopathology; Does not cover all specific GN subtypes in detail; Immunosuppression regimens vary by center. Individual patient factors may require deviation from these recommendations.
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