Glomerulonephritis Student Feedback – From Hailey McNabb

Glomerulonephritis (GN) is a hypersensitivity III reaction, which, in Ren’s case, developed from a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection. MRSA antigens activate T cells, leading to B cell production and antibody generation. These antibodies bind to one another, forming immune complexes, with IgA being the most prevalent.

These soluble immune complexes, which result from a higher number of antigens to antibodies, circulate within the bloodstream and deposit into the kidneys and activate the complement system through the classical pathway. This initiates inflammation through opsonization, chemotaxis, mast cell degranulation, and membrane attack complexes. Inflammatory mediators and complement proteins travel to the injury site which causes the bowman’s capsule membrane cells to rapidly multiply, resulting in a thickening of the membrane walls.

Due to the membrane thickening, Ren’s kidneys cannot effectively clear wastes, and because of this excess inflammation, hematuria and proteinuria are present. This inflammation may also lead to anuria or oliguria. As the body continues to be unable to filter these waste products, we see an increased intravascular volume, resulting in edema and systemic hypertension.

In order to diagnose GN the following tests and assessments should be completed: Renal ultrasound, renal biopsy, electron microscopy, immunofluorescence microscopy, CBC, blood cultures, renal function test, and a urinalysis. These testing methods help to confirm the diagnosis, evaluate the current state of infection/illness, and assist in choosing appropriate further therapies.

The presence of blood urea nitrogen, C-reactive protein, and lipids in a urinalysis, as well as a low glomerular filtration rate, prove that the kidneys are impaired and are unable to effectively filter wastes. Low levels of C3 and C4 and elevated C-reactive proteins are key indicators of the ongoing inflammatory process of GN.

The first line of treating GN is removing the antigen, in Ren’s case, MRSA. This can be treated through the use of Vancomycin. Other medications including antihypertensives, and diuretics, as well as implementing a restriction on salt, can help in reducing the associated GN symptoms of edema and hypertension. ACEs and ARBs will aid in protecting the kidneys through the management of blood pressure to minimize its impact on the glomeruli. Corticosteroids can help in reducing the inflammation process and immunosuppressive medications can help in limiting the immune response that contributes to the disease. While plasma exchange may be another option in helping to remove harmful products in the blood.

The content provided in this podcast was thorough and clearly defined, however, there are a few sections that I would suggest having further explanation to enhance listeners’ knowledge on the topic!

Regarding the section that describes Ren’s symptoms of hematuria and proteinuria, I feel that I would have had a better understanding of the content if there had been further explanation on how these symptoms were directly linked to the kidney’s inflammatory process. For example, “Damage to the glomerular capillaries during the process of inflammation results in them becoming more permeable. This increase in permeability allows red blood cells, which are usually too large to pass through, to leak into the urine.” I do recognize that this content was discussed in previous pathophysiology courses, but I feel that this reminder and a more focused lens on the inflammation side of GN would have been a relevant way to make this section more thorough. I would be curious to hear further about which chemical mediators played key roles in increasing permeability in this condition and if any cells directly attacked the glomerular membrane!

Another area that would be beneficial to explore further is the relationship between immune complexes and why and how they specifically deposit within the glomerulus. Understanding why these complexes target the glomerulus compared to other features within the kidney, could provide a more robust understanding of how GN is unique in comparison to other hypersensitivity III reactions.

Due to the uniqueness of Ren having an MRSA-associated GN, providing further clarification on why IgA antibodies are prominent in this infection could have been an interesting lens to take. I wonder if say an MRSA-associated GN versus a hepatitis-associated GN would differ with immunoglobulin production?

One of the learning strategies implemented in this project effectively was the use of a relevant case-based teaching approach that helped in developing a clear trajectory for the progression of GN. Selecting MRSA as the underlying factor for developing GN was applicable to our daily nursing practice; MRSA is one of the most common bacteria seen in the hospital. Using a case study to describe the learning of this pathophysiology helped in bridging the gap between understanding theoretical knowledge and practical application.

By focusing on Ren, the case study was able to clearly define how GN evolves, effectively integrating how MRSA infections can trigger immune complex formation, activate the complement system, and eventually lead to renal inflammation and damage. Each speaker’s use of questioning during the podcast, alternating with a clear pathophysiology description, helped clarify difficult concepts and allowed me to have a more concrete understanding of this reaction.

Within the case study, they also had the addition of Ren being seen in the emergency room. I felt that this step in Ren being diagnosed was another realistic situation that was provided, as many patients first access the healthcare system through the emergency department. During this segment, the podcast went through some of the initial testing that would be completed, like a wound swab and some standard blood work. This phase in the story helped me recognize how the diagnosis of GN would require a lengthy series of tests.

The case study in a podcast style provided me with a structured learning environment that facilitated me to actively engage in the content and critically think. Overall, this learning strategy was effective as it made complex concepts into digestible chunks, reinforcing my new understanding of how GN fits into the category of a hypersensitivity III reaction.

One suggestion that I would recommend to enhance the creativity and clarity of this content in a podcast style would be to integrate sound effects when describing GN pathophysiology. When using a podcast format to explain content, it can be hard for listeners to envision the complex processes being described. Including sound effects throughout the learning experience may help to create a more memorable and captivating learning experience. Selecting sounds that are fun and unique to the information being described could help listeners follow the pathophysiology better, even without the visual aspect. This adaptation could also help listeners with different learning styles, helping them to better understand the concepts being described.

For example, when discussing how after exposure to the MRSA antigen, soluble immune complexes form and circulate in the bloodstream before they deposit into the glomerulus, which then triggers the complement system. Sound effects during these key steps could make the steps more memorable. A “swish/whoosh” could represent the complexes travelling throughout the bloodstream, followed by a “clunk” once they deposit into the glomerulus. Then, a “ding” or “click” could be the activation of the complement system. Along with these more basic sounds, the podcast could include more funny audio clips, specifically, when describing some of the complement systems functions. When the topic of opsonization is brought up, they could add a playful “yum” sound effect, or with chemotaxis, they could add a “whistle” effect to emphasize the calling and recruitment of other immune cells.

Adding these small but entertaining audio effects could help listeners understand the concepts being discussed by adding a fun element to a heavy topic. This addition would both improve listener engagement and create a unique learning experience.

As a future registered nurse, I plan to apply the knowledge I gained from the GN teaching in this podcast to enhance my patient assessments, care planning, and education. Specifically, I will use this information to earlier identify and manage patients who are at risk of developing GN, especially those with MRSA.

When assessing my patients in the future, I will be more mindful of the signs and symptoms of GN, such as hematuria, proteinuria, edema, and hypertension. The insight I have gained on the pathophysiology associated with GN will allow me to consider renal impairment as a possible link to these symptoms during my head-to-toe assessment. By proactively looking for these signs, I will be better able to support my patients in earlier detection of this condition and implement the proper actions to prevent further kidney damage.

If I anticipate a potential for renal impairment, I can help to advocate for earlier diagnostic testing and implement appropriate interventions. I could recommend a urinalysis, renal panel, and complement protein level testing. By knowing why and how these tests are used, I will be more informed in asking for them to be integrated into the care plan. When results appear, I will also be better able to recognize their connection to renal function. Additionally, when providing medications such as antihypertensives or diuretics, I will have more knowledge on how these pharmaceuticals are directly targeting and supporting our patients with GN. With this, I will continue to monitor for a trend of a hopeful decrease in inflammatory markers, indicating that our treatments are working.

Another point I can take away from this podcast is being able to inform and educate my patients about those diagnosed or at risk of developing GN. I can educate my patients on the importance of timely treatment of infections and provide them knowledge on the signs and symptoms to report that may indicate renal impairment (ex. Swelling of the extremities, changes in the colour of their urine). For those who are diagnosed with GN, I can also educate them on possible lifestyle modifications, such as regulating the amount of sodium in their diet, to help in managing symptoms of edema and hypertension.