Acute Glomerulonephritis: A history of recent infection or search for any underlying systemic disease is the first part of any case taking related to suspected Glomerular diseases.
The most common infection observed is with nephritogenic group A beta-hemolytic streptococcal infection. There should be a history of throat infections like pharyngitis or skin infections like impetigo.
Other Triggering infections: Staphylococcus aureus, bacterial pneumonitis, infective endocarditis, and different viral, fungal, and parasitic causes, including HIV and hepatitis B, C, etc. It may even be associated with glandular fever, infectious mononucleosis, syphilis, malaria, cytomegalo, and toxoplasmosis virus infections.
Incubation period: Estimated average 7-10 days.
Clinical Presentations ( infection-related AGN):
- Asymptomatic in minimal lesion glomerulonephritis.
- Haematuria or smoky coloured urine, Hypertension and maybe hypercholesterolaemia in nephrotic syndrome type.
- Oliguria is present in the acute renal failure stage.
Investigations:
- Anti-streptolysin O titer remains high.
- RBC cast and protein in urine will remain high.
- Low Serum Complement level.
- Kidney Biopsy: A proliferative pattern may be seen in the nephrotic type.
- Immunofluorescence study: accumulation of immunoglobulins IgG and C3 in the capillary basement membrane.
- Electron microscopy – Sub epithelial deposits (Humps)
Glomerulopathy related to Immunioglobulin A(IgA):
It is the most common primary glomerulopathy in Asia. It occurs due to abnormal deposition of immunocomplex (development of autoantibodies, IgG, related to genetically acquired glycosylated IgA) at glomerular mesangial space. It may be of pure renal origin or secondary to other diseases like chronic liver disease, coeliac disease, CMV infections or HIV infections.
Incubation period: Short.
Clinical Presentations ( Infection-related AGN):
- Upper Respiratory viral infection with haematuria.
- Microscopic haematuria is the most common finding.
- Smoky coloured urine.
- Proteinuria – minimum to gross as per the progress of renal pathology.
- Common to children and young.
- While many patients have a fair prognosis, a few have severe kidney injury and proteinuria, which might indicate disease progression.
Investigations:
- Normal Serum Complement level.
- Kidney Biopsy – proliferative pattern with focal glomerulonephritis.
- Immunofluorescence study – mesangial deposition of immunoglobulins IgG and C3.
Glomerulopathy related to Henoch-Schonlein Purpura:
It is a form of vasculitis related to glomerulonephritis. It is very common in children.
Clinical Presentations:
- Systemic vasculitis of auto-immune origin (related to IgA)
- Purpuric spots can be found in the legs and hip area.
- Arthralgia with associated symptoms of pain in the abdomen, nausea, and black stool may be the presenting features.
- Sediment in urine and acute renal injury features may be seen in progressive disease in adults.
Investigations:
- Microscopic haematuria.
- Proteinuria – very less.
- Kidney Biopsy – proliferative pattern like focal glomerulonephritis.
Pauci-immune Glomerulonephropathy(Anti neutrophil cytoplasmic antibody-related)
It is seen in conditions where systemic vasculitis is not present and the pathology is limited to the kidney only, as an immunofluorescence study of a kidney biopsy reveals a lack of immunoglobulin and/or complement accumulation, so the terminology ‘pauci-immune’ evolved. The pathology of vascular damage is different here.
Clinical Presentations:
- Fever, malaise, weight loss.
- Haematuria, proteinuria, purpura.
- In most of the patients, respiratory infections, sinusitis, and even hemoptysis can be seen.
- Low immunity.
- Prognosis: If treated, chances of recovery can be seen in many patients with certain limitations. High ANCA titres may be indicative of prognosis.
Investigations:
- Presence of ANCA in blood. (serological confirmatory test )
- Kidney Biopsy – ‘crescent’ kidney.
Glomerulonephropathy and Goodpasture Syndrome:
It is also called anti-GBM disease, in which autoantibodies develop in respect of the glomerular basement membrane with simultaneous autoimmune activities at the pulmonary field, like the alveolar basement membrane, causing pulmonary haemorrhage. This is known as Goodpasture Syndrome. The syndrome usually appears at a young age but is not rare in older age too, in which respiratory signs are more common. A few predisposing factors like smoking, existing chronic infection, and HLA-DR2 antigens are extremely important in the development of this type.
Clinical Presentations:
- The prodromal phase includes upper respiratory tract infection, which may be followed by haemoptysis and shortness of breath. Even if the disease progresses too much, then respiratory failure also may occur.
- In a few groups of patients, there may be minimum renal damage, and clinical features of renal origin are observed.
- Haematuria, characteristic of any glomerulopathy, may be observed in a very mild form.
- Prognosis depends on the severity of kidney damage. The patient with anuria or oliguria with acute renal damage has a very poor prognosis.
Investigations:
- Presence of anti-GBM antibodies in blood. (serological confirmatory test)
- Complement levels remain normal in serum.
- Radiological findings through CXR: pulmonary haemorrhagic sign.
- Kidney Biopsy: ‘crescent’ kidney.
Glomerulonephropathy in Membranous Glomerulonephritis:
It is a rare condition. In the auto immune-mediated type, different predisposing factors include different existing autoimmune diseases, existing infections (bacterial or parasitic), hepatitis C viral infection, etc. In young individuals, it may be of idiopathic origin. Clinical features observed from minimal haematuria or an asymptomatic state to massive haematuria and an acute form of glomerular nephritis. Low complement factors C3 and C4 are noted in C3 glomerulonephritis associated with membranous GN. In electron microscopy, mesangial deposits are noted (“tram track appearance”), which give shape to the double-line layer of the Glomerular basement membrane.
Another variety of Glomerulonephritis about HCV is not rare in which different types of renal injuries are observed and symptoms appear depending on the pattern of injuries. Serum transaminases and rheumatoid factors are found elevated. Decreasing viral load can ensure a speedy recovery.
Glomerular nephritis and Systemic Lupus Erythematosus:
Most of the patients with SLE may present features of renal diseases. Autoimmune pathology is the basic etiological factor. It may be in the form of proteinuria, haematuria, high creatinine level, etc. There may be a minimal lesion of the kidney or a minimal proliferative lesion of the kidney in which recovery ensues, and in many cases, treatment may not be required. In another group where localized or focal and diffuse glomerulopathy develops, serious attention is to be given to the treatment approach. The advanced pathology in the form of glomerular sclerosis or very thick glomerulus membranopathy may cause a severe form of renal damage that may reach an incurable state. In another type, non-glomerular involvement may be seen in the form of vasculitis and tubulointerstitial nephritis in a patient with SLE. Male patients with high serum creatinine levels have poor prognosis. In the advanced stage or transformation of the stage disease to a more active form, it can be diagnosed by a high titre of anti-DS-DNA and a low serum complement factor.
Homoeopathic approach:
It is a well-known fact to homoeopathic professionals that the holistic view and dynamic pathology are the two most important criteria to perceive disease from a homoeopathic point of view.
The presentation of different diseases is different, which can be diagnosed by differential diagnosis through clinical symptomatology along with laboratory investigation and radiological evidence.
The homoeopathic approach adds something more to clinical diagnosis under which the cause of the cause concept (ultimate cause) along with constitutional/individualistic, miasmatic dyscrasia and susceptibility concepts are of utmost importance.
If we consider the common diseases of the kidney, then the discussion is required as per individual disease, always considering the person in a different state of kidney disease.
In acute glomerulonephritis, the basic pathology is considered to be molecular mimicry following streptococcal infection of the patient. This autoimmune theory reveals that the human body may misidentify its substance following some triggering factor. So, in AGN, the Glomerular Basement Membrane antibody may be produced by the misdirected immune response related to molecular mimicry of Streptococcal antigen with GBM antigens. So, the very basic concept of “Misdirected” immune response may be considered a purely functional disorder, which indicates Psora miasm as the background of the disease from the concept of dynamic pathology.
Now, it is evident from clinical medicine that the progression of a patient suffering from AGN differs from man to man. Here the homoeopathic understanding will help a homoeopath to get clues regarding the prognosis of the disease if the patient’s thorough case-taking can be done as directed by homoeopathic philosophy (complete symptoms with modalities and concomitant, history and chronology of diseases suffered from, family history, generalities, etc.). The predominant tent of Miasm, along with accessory circumstances, will indicate the advancement of the disease with time. The destruction, which means loss of nephron, may be more common in a patient with predominant syphilitic miasm, whereas proliferative changes of the Glomerular basement membrane will be an obvious feature of a patient with predominant sycotic miasm.
The destruction of the production of autoantibodies and the release of cytokines are indicative of sycotic predominance. The mixed miasmatic state of the patient will produce mixed types of clinical features depending on the dominant miasm at a given period.
Thus, in homoeopathy, any disease cannot be marked by any specific type of miasm related to the disease, e.g., in AGN.
- The patient with psoric tendencies may recover early, while the advanced stage of acute glomerulonephritis converting to chronic glomerulonephritis may be indicative of a mixed miasmatic state with sycotic miasm as a dominant one. So, the scanty urine or oliguria of AGN may be psoric in most cases, while polyuria of chronic glomerulonephritis indicates psora-sycotic miasm.
- So, it may be assumed that the individual constitution, miasmatic tendencies of individual patients, and the accessory circumstances are the conditions based on which the disease develops, progresses, clinical symptoms appear, and in the long run, complications develop.
- So, understanding a patient’s economy and constitution will help a homoeopath to perceive the course of disease in a person in a given period and circumstances.
Homoeopathic Remedies:
A huge number of homoeopathic medicines have multiple symptoms of kidney diseases, which can be useful if symptoms correspond to the Homoeopathic principle during treatment. Treating chronic renal diseases is one of the most challenging tasks to accomplish, for which the importance of detailed, exhausted case-taking with chronological records, family history along with personal history, and/or generalities is of utmost importance, as well as based on which the true totality of symptoms can be built up after evaluating rationally according to homoeopathic philosophy. The potency, dose, and repetition will depend on the stage of the disease, the susceptibility of the patient in a given period, and accessory circumstances. The environmental, social, economic, political, as well as multiple events of life, etc., are to be taken care of to perceive the real anamnesis of a CKD case.
Apart from the palliative mode of treatment (which may be required in many advanced cases where pathology is in a gross damage state), the constitutional approach will certainly give good results in CKD cases. The following few remedies with their indications in cases of CKD are to be noted:
- Apis mel – typical puffiness, thirstless, burning pain, strangury, post-infection etc.
- Arsenicum album – waxy pale skin, anasarca, restlessness, burning sensation, despair.
- Mercurius cor.– in the late stage more indicated, strangury is too much, post-infective, red cast, profuse saliva with thirst, uneasiness on face, syphilitic, large white kidney etc.
- Cantharis – typical burning, cutting pain at lumbar region and frequent micturition, post-infective, Sun aggravation.
- Kali ars – in the advanced stage when acute nephritis progresses to acute renal failure.
- Kali chlor – symptoms very much correspond to the acute form of nephritis.
- Convaleria majus – Nephritis related to heart diseases.
- Apocyanum c.- may be used to decrease ascites, mostly used as palliative.
- Digitalis – Marked action on kidney, associated weak heart symptoms, weak circulation.
- Glonoine – acute hemorrhagic nephritis, may be of reflex heart complications.
- Phosphorus – one of the best remedies but usually indicated in a later stage.
- Terebinth – Most reliable remedy in acute nephritis presenting with massive haematuria.Typical prostration with symptoms of haematuria.
In the acute stage, the symptoms of the remedy closely resemble the totality of symptoms in a patient suffering from acute glomerulonephritis, which is of prime focus. More emphasis is given to presenting symptoms with modalities. The sub-acute or chronic form will also be treated with similar approaches.
Clinical medicine changed itself with time. One disease, here Glomerulonephritis, manifested in different forms in different stages. The clinical features of different varieties are to be differentiated through clinical features and laboratory investigatory findings. So, clinical medicine too, differentiates the different subtypes of one disease through its group-specific clinical and laboratory findings. From a Homeopathic understanding, one homeopath can perceive that the patient with predominant psoric miasmatic dyscrasia may produce a minimal lesion of glomerular nephritis, or in a later stage it will never cause gross organ damage. Accordingly, thick GBM diseases or proliferative glomerulopathies are common presentations in the person having predominant sycotic miasmatic dyscrasia and glomerular sclerosis in the syphilitic miasmatic dyscrasia. So, the advantage of Homoeopathic philosophy is that it can assume the tendencies, progress, and prognosis of any disease in a person depending on miasmatic dyscrasias, individual constitutions (genetic make-up), and accessory circumstances (epigenetics).