{"id":37023,"date":"2026-06-11T14:38:39","date_gmt":"2026-06-11T09:08:39","guid":{"rendered":"https:\/\/atsixty.com\/?p=37023"},"modified":"2026-06-11T14:39:13","modified_gmt":"2026-06-11T09:09:13","slug":"glomerular-diseases","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/neet-pg\/glomerular-diseases\/","title":{"rendered":"Glomerular Diseases"},"content":{"rendered":"\n\n\n<meta charset=\"UTF-8\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n<title>Morning Rounds \u00b7 Glomerular Diseases<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n#nep03 *,#nep03 *::before,#nep03 *::after{box-sizing:border-box;margin:0;padding:0}\n#nep03{\n  --nep:#2A5470;\n  --nep-light:#3A7499;\n  --nep-pale:#EBF3F8;\n  --nep-dark:#1C3D52;\n  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font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Nephrotic vs Nephritic Syndrome<\/text>\n      <!-- Headers -->\n      <rect x=\"10\" y=\"22\" width=\"120\" height=\"20\" rx=\"3\" fill=\"#4a7a9b\"\/>\n      <rect x=\"136\" y=\"22\" width=\"190\" height=\"20\" rx=\"3\" fill=\"#2A5470\"\/>\n      <rect x=\"332\" y=\"22\" width=\"198\" height=\"20\" rx=\"3\" fill=\"#1C3D52\"\/>\n      <text x=\"70\"  y=\"35\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Feature<\/text>\n      <text x=\"231\" y=\"35\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Nephrotic<\/text>\n      <text x=\"431\" y=\"35\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Nephritic<\/text>\n      <!-- Row 1 -->\n      <rect x=\"10\"  y=\"44\" width=\"120\" height=\"20\" rx=\"2\" fill=\"#d4e8f4\"\/>\n      <rect x=\"136\" y=\"44\" width=\"190\" height=\"20\" rx=\"2\" fill=\"#eaf6ef\"\/>\n      <rect x=\"332\" y=\"44\" width=\"198\" height=\"20\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"70\"  y=\"57\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\">Proteinuria<\/text>\n      <text x=\"231\" y=\"57\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">&gt;3.5 g\/day (massive)<\/text>\n      <text x=\"431\" y=\"57\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">&lt;3.5 g\/day (mild\u2013mod)<\/text>\n      <!-- Row 2 -->\n      <rect x=\"10\"  y=\"66\" width=\"120\" height=\"20\" rx=\"2\" fill=\"#c4dff0\"\/>\n      <rect x=\"136\" y=\"66\" width=\"190\" height=\"20\" rx=\"2\" fill=\"#eaf6ef\"\/>\n      <rect x=\"332\" y=\"66\" width=\"198\" height=\"20\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"70\"  y=\"79\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\">Haematuria<\/text>\n      <text x=\"231\" y=\"79\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Absent \/ minimal<\/text>\n      <text x=\"431\" y=\"79\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Prominent (RBC casts)<\/text>\n      <!-- Row 3 -->\n      <rect x=\"10\"  y=\"88\" width=\"120\" height=\"20\" rx=\"2\" fill=\"#d4e8f4\"\/>\n      <rect x=\"136\" y=\"88\" width=\"190\" height=\"20\" rx=\"2\" fill=\"#eaf6ef\"\/>\n      <rect x=\"332\" y=\"88\" width=\"198\" height=\"20\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"70\"  y=\"101\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\">Oedema<\/text>\n      <text x=\"231\" y=\"101\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Severe (hypoalbuminaemia)<\/text>\n      <text x=\"431\" y=\"101\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">Mild\u2013moderate (Na retention)<\/text>\n      <!-- Row 4 -->\n      <rect x=\"10\"  y=\"110\" width=\"120\" height=\"20\" rx=\"2\" fill=\"#c4dff0\"\/>\n      <rect x=\"136\" y=\"110\" width=\"190\" height=\"20\" rx=\"2\" fill=\"#eaf6ef\"\/>\n      <rect x=\"332\" y=\"110\" width=\"198\" height=\"20\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"70\"  y=\"123\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\">BP \/ renal fn<\/text>\n      <text x=\"231\" y=\"123\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Usually normal initially<\/text>\n      <text x=\"431\" y=\"123\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Hypertension + &#x2191; creatinine<\/text>\n      <!-- Row 5: causes -->\n      <rect x=\"10\"  y=\"132\" width=\"120\" height=\"46\" rx=\"2\" fill=\"#d4e8f4\"\/>\n      <rect x=\"136\" y=\"132\" width=\"190\" height=\"46\" rx=\"2\" fill=\"#e8f3f9\"\/>\n      <rect x=\"332\" y=\"132\" width=\"198\" height=\"46\" rx=\"2\" fill=\"#f4eef8\"\/>\n      <text x=\"70\"  y=\"146\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\">Common causes<\/text>\n      <text x=\"231\" y=\"145\" text-anchor=\"middle\" fill=\"#2A5470\" font-size=\"7\" font-family=\"Georgia,serif\">MCD (children)<\/text>\n      <text x=\"231\" y=\"156\" text-anchor=\"middle\" fill=\"#2A5470\" font-size=\"7\" font-family=\"Georgia,serif\">FSGS, MGN (adults)<\/text>\n      <text x=\"231\" y=\"167\" text-anchor=\"middle\" fill=\"#2A5470\" font-size=\"7\" font-family=\"Georgia,serif\">Diabetic nephropathy, Amyloid<\/text>\n      <text x=\"431\" y=\"145\" text-anchor=\"middle\" fill=\"#5a2a7a\" font-size=\"7\" font-family=\"Georgia,serif\">IgA nephropathy<\/text>\n      <text x=\"431\" y=\"156\" text-anchor=\"middle\" fill=\"#5a2a7a\" font-size=\"7\" font-family=\"Georgia,serif\">Post-strep GN, RPGN<\/text>\n      <text x=\"431\" y=\"167\" text-anchor=\"middle\" fill=\"#5a2a7a\" font-size=\"7\" font-family=\"Georgia,serif\">Lupus nephritis, MPGN<\/text>\n    <\/svg>\n    <figcaption>\n      The nephrotic\u2013nephritic distinction is a fundamental framework. Some conditions overlap both (e.g. MPGN, lupus nephritis class IV). RBC casts on urine microscopy are pathognomonic of glomerulonephritis \u2014 their presence always points to a nephritic process.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<!-- Lupus nephritis ISN\/RPS classes for Q5 debrief -->\n<div id=\"nep03-img5\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 520 162\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:520px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"520\" height=\"162\" rx=\"8\" fill=\"#f0f6fa\"\/>\n      <text x=\"260\" y=\"15\" text-anchor=\"middle\" fill=\"#1A2C38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Lupus Nephritis \u2014 ISN\/RPS 2003 Classification<\/text>\n      <!-- Headers -->\n      <rect x=\"10\" y=\"20\" width=\"50\"  height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n      <rect x=\"64\" y=\"20\" width=\"200\" height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n      <rect x=\"268\" y=\"20\" width=\"242\" height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n      <text x=\"35\"  y=\"32\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Class<\/text>\n      <text x=\"164\" y=\"32\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Histology<\/text>\n      <text x=\"389\" y=\"32\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Clinical \/ Significance<\/text>\n      <!-- I -->\n      <rect x=\"10\" y=\"40\" width=\"50\"  height=\"18\" rx=\"2\" fill=\"#eaf6ef\"\/>\n      <rect x=\"64\" y=\"40\" width=\"200\" height=\"18\" rx=\"2\" fill=\"#f4faf8\"\/>\n      <rect x=\"268\" y=\"40\" width=\"242\" height=\"18\" rx=\"2\" fill=\"#f4faf8\"\/>\n      <text x=\"35\"  y=\"52\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">I<\/text>\n      <text x=\"164\" y=\"52\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">Minimal mesangial<\/text>\n      <text x=\"389\" y=\"52\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">Normal light microscopy; EM deposits only<\/text>\n      <!-- II -->\n      <rect x=\"10\" y=\"60\" width=\"50\"  height=\"18\" rx=\"2\" fill=\"#eaf6ef\"\/>\n      <rect x=\"64\" y=\"60\" width=\"200\" height=\"18\" rx=\"2\" fill=\"#edf8f4\"\/>\n      <rect x=\"268\" y=\"60\" width=\"242\" height=\"18\" rx=\"2\" fill=\"#edf8f4\"\/>\n      <text x=\"35\"  y=\"72\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">II<\/text>\n      <text x=\"164\" y=\"72\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">Mesangial proliferative<\/text>\n      <text x=\"389\" y=\"72\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">Mild haematuria \/ proteinuria; good prognosis<\/text>\n      <!-- III -->\n      <rect x=\"10\" y=\"80\" width=\"50\"  height=\"18\" rx=\"2\" fill=\"#fff5e0\"\/>\n      <rect x=\"64\" y=\"80\" width=\"200\" height=\"18\" rx=\"2\" fill=\"#fffaf0\"\/>\n      <rect x=\"268\" y=\"80\" width=\"242\" height=\"18\" rx=\"2\" fill=\"#fffaf0\"\/>\n      <text x=\"35\"  y=\"92\" text-anchor=\"middle\" fill=\"#7a5000\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">III<\/text>\n      <text x=\"164\" y=\"92\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">Focal proliferative (&lt;50% glomeruli)<\/text>\n      <text x=\"389\" y=\"92\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">Active nephritis; treat with immunosuppression<\/text>\n      <!-- IV -->\n      <rect x=\"10\" y=\"100\" width=\"50\"  height=\"18\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <rect x=\"64\" y=\"100\" width=\"200\" height=\"18\" rx=\"2\" fill=\"#fdf5f5\"\/>\n      <rect x=\"268\" y=\"100\" width=\"242\" height=\"18\" rx=\"2\" fill=\"#fdf5f5\"\/>\n      <text x=\"35\"  y=\"112\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">IV<\/text>\n      <text x=\"164\" y=\"112\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Diffuse proliferative (&#x2265;50% glomeruli)<\/text>\n      <text x=\"389\" y=\"112\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Most severe; worst prognosis; treat aggressively<\/text>\n      <!-- V -->\n      <rect x=\"10\" y=\"120\" width=\"50\"  height=\"18\" rx=\"2\" fill=\"#e8f3f9\"\/>\n      <rect x=\"64\" y=\"120\" width=\"200\" height=\"18\" rx=\"2\" fill=\"#f0f6fb\"\/>\n      <rect x=\"268\" y=\"120\" width=\"242\" height=\"18\" rx=\"2\" fill=\"#f0f6fb\"\/>\n      <text x=\"35\"  y=\"132\" text-anchor=\"middle\" fill=\"#2A5470\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">V<\/text>\n      <text x=\"164\" y=\"132\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">Membranous<\/text>\n      <text x=\"389\" y=\"132\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">Nephrotic; can coexist with class III or IV<\/text>\n      <!-- VI -->\n      <rect x=\"10\" y=\"140\" width=\"50\"  height=\"18\" rx=\"2\" fill=\"#d4e8f4\"\/>\n      <rect x=\"64\" y=\"140\" width=\"200\" height=\"18\" rx=\"2\" fill=\"#eaf3f8\"\/>\n      <rect x=\"268\" y=\"140\" width=\"242\" height=\"18\" rx=\"2\" fill=\"#eaf3f8\"\/>\n      <text x=\"35\"  y=\"152\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">VI<\/text>\n      <text x=\"164\" y=\"152\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">Advanced sclerosing (&gt;90% sclerosed)<\/text>\n      <text x=\"389\" y=\"152\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7.5\" font-family=\"Georgia,serif\">End-stage; immunosuppression not beneficial<\/text>\n    <\/svg>\n    <figcaption>\n      Class IV (diffuse proliferative) is the most common and most severe form of lupus nephritis. Treatment: induction with MMF or IV cyclophosphamide + high-dose corticosteroids, followed by maintenance MMF or azathioprine. Renal biopsy is required for classification and guides treatment intensity.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<div id=\"nep03\">\n\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds \u00b7 Nephrology Series \u00b7 Round 03<\/div>\n    <div class=\"mr-title\">\n      Glomerular Diseases<br><em>Nephrotic, Nephritic &amp; Beyond<\/em>\n    <\/div>\n    <div class=\"mr-subtitle\">Five cases &middot; Read carefully &middot; Trust your instinct<\/div>\n    <div class=\"mr-chips\">\n      <span class=\"mr-chip\">5 Cases<\/span>\n      <span class=\"mr-chip\">+4 \/ &minus;1 scoring<\/span>\n      <span class=\"mr-chip\">Options reshuffled<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-sentinel\" id=\"nep03-sentinel\"><\/div>\n\n  <div class=\"mr-progress\" id=\"nep03-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"nep03-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"nep03-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"nep03-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"nep03-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"nep03-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"nep03-pct\">0%<\/span>\n            <span class=\"mr-ring-sub\">net<\/span>\n          <\/div>\n        <\/div>\n        <div class=\"mr-score-title\">Your Debrief<\/div>\n        <div class=\"mr-score-net\" id=\"nep03-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"nep03-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"nep03-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"nep03-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"nep03-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"nep03-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n\n<\/div><!-- end #nep03 -->\n\n<script>\n(function () {\n  'use strict';\n\n  var NS    = 'nep03';\n  var TOTAL = 5;\n  var MAX   = 20;\n  var LTRS  = ['A','B','C','D'];\n\n  var QS = [\n\n    {\n      id:      1,\n      tag:     'Glomerular Disease &mdash; Nephrotic vs Nephritic',\n      stem:    'A <strong>6-year-old boy<\/strong> presents with periorbital puffiness for 5 days, worsening facial and leg swelling, and frothy urine. He has no haematuria. Investigations: urine protein 4+ on dipstick, 24-hour urinary protein <strong>5.8 g\/day<\/strong>, serum albumin <strong>1.6 g\/dL<\/strong>, serum cholesterol elevated, creatinine normal, BP normal. Urine microscopy shows no RBC casts. What is the syndrome and the most likely underlying diagnosis?',\n      correct: 'Nephrotic syndrome; minimal change disease (MCD)',\n      opts: [\n        'Nephrotic syndrome; minimal change disease (MCD)',\n        'Nephritic syndrome; post-streptococcal glomerulonephritis',\n        'Nephrotic syndrome; focal segmental glomerulosclerosis (FSGS)',\n        'Mixed nephrotic-nephritic; IgA nephropathy'\n      ],\n      exp:     'The triad of <strong>massive proteinuria (&gt;3.5 g\/day)<\/strong>, <strong>hypoalbuminaemia<\/strong>, and <strong>oedema<\/strong> \u2014 without haematuria, hypertension, or renal impairment \u2014 defines <strong>nephrotic syndrome<\/strong>. In a child under 10 with no haematuria and normal complement, the diagnosis is <strong>minimal change disease (MCD)<\/strong> until proven otherwise \u2014 it accounts for 90% of childhood nephrotic syndrome. MCD is characterised by normal light microscopy, negative immunofluorescence, and <strong>podocyte foot process effacement on electron microscopy<\/strong>. It is steroid-responsive in ~90% of children. Biopsy is generally deferred in children with a typical first presentation and commenced on empirical prednisolone. FSGS is more common in adults and is steroid-resistant.',\n      imgId:   'nep03-img1'\n    },\n\n    {\n      id:      2,\n      tag:     'Glomerular Disease &mdash; IgA Nephropathy',\n      stem:    'A <strong>22-year-old man<\/strong> presents with <strong>macroscopic haematuria<\/strong> that began <strong>24 hours after an upper respiratory tract infection<\/strong>. He has mild proteinuria (0.8 g\/day) and BP 136\/88 mmHg. Serum creatinine is <strong>1.4 mg\/dL<\/strong>. Throat swab is negative. Complement C3 and C4 are <strong>normal<\/strong>. Urine microscopy shows dysmorphic RBCs and 2\u20133 RBC casts. What is the most likely diagnosis?',\n      correct: 'IgA nephropathy (Berger\\'s disease)',\n      opts: [\n        'IgA nephropathy (Berger\\'s disease)',\n        'Post-streptococcal glomerulonephritis (PSGN)',\n        'Thin basement membrane disease',\n        'Alport syndrome'\n      ],\n      exp:     '<strong>IgA nephropathy<\/strong> is the commonest primary glomerulonephritis worldwide. The hallmark is <strong>synpharyngitic haematuria<\/strong> \u2014 macroscopic haematuria occurring <strong>concurrently with or within 1\u20132 days of<\/strong> an URTI (unlike PSGN, where haematuria follows the infection by <strong>1\u20133 weeks<\/strong> \u2014 the latent period). <strong>Normal complement<\/strong> is a key distinguishing feature from PSGN (C3 low in PSGN). Diagnosis is confirmed by renal biopsy showing <strong>mesangial IgA deposits on immunofluorescence<\/strong>. Thin basement membrane disease causes persistent microscopic haematuria without RBC casts or proteinuria. Alport syndrome is X-linked, has sensorineural deafness and ocular abnormalities, and typically presents in boys with a family history. Management of IgA nephropathy: RAS blockade for proteinuria, SGLT2i increasingly used, immunosuppression in progressive disease.',\n      imgId:   null\n    },\n\n    {\n      id:      3,\n      tag:     'Glomerular Disease &mdash; Membranous Nephropathy',\n      stem:    'A <strong>45-year-old man<\/strong> has a 3-month history of bilateral leg swelling. Investigations: 24-hour urine protein <strong>7.2 g\/day<\/strong>, serum albumin 2.2 g\/dL, creatinine 1.1 mg\/dL, BP 138\/86 mmHg. Renal biopsy shows <strong>diffuse thickening of the glomerular basement membrane<\/strong>, subepithelial immune deposits on electron microscopy, and <strong>positive anti-PLA2R antibody<\/strong>. What is the diagnosis and the significance of the PLA2R antibody?',\n      correct: 'Primary (idiopathic) membranous nephropathy; anti-PLA2R confirms primary aetiology and correlates with disease activity',\n      opts: [\n        'Primary (idiopathic) membranous nephropathy; anti-PLA2R confirms primary aetiology and correlates with disease activity',\n        'Secondary membranous nephropathy due to malignancy; anti-PLA2R is positive in paraneoplastic cases',\n        'Focal segmental glomerulosclerosis; anti-PLA2R is a non-specific marker of podocyte injury',\n        'Membranoproliferative GN; anti-PLA2R positivity distinguishes it from lupus nephritis class V'\n      ],\n      exp:     '<strong>Membranous nephropathy (MGN)<\/strong> is the commonest cause of nephrotic syndrome in <em>adults<\/em> in the Western world; in India, it ranks after FSGS and minimal change disease. Anti-<strong>PLA2R (phospholipase A2 receptor)<\/strong> antibodies are present in <strong>70\u201380% of primary MGN<\/strong> cases. Positive anti-PLA2R: (1) confirms primary MGN, (2) correlates with disease activity and proteinuria, (3) guides treatment \u2014 high titres predict need for immunosuppression, and falling titres indicate remission. <strong>Secondary MGN<\/strong> (malignancy, HBV, SLE, drugs \u2014 penicillamine, gold, NSAIDs) is <em>anti-PLA2R negative<\/em>. The classic EM finding is <strong>subepithelial deposits<\/strong> (\"spike and dome\" appearance on silver stain). Treatment of primary MGN: RAS blockade first; if nephrotic range persists, rituximab (now preferred) or cyclophosphamide-based regimens.',\n      imgId:   null\n    },\n\n    {\n      id:      4,\n      tag:     'Glomerular Disease &mdash; Rapidly Progressive GN',\n      stem:    'A <strong>35-year-old woman<\/strong> presents with 3 weeks of haematuria, oliguria, and rapidly rising creatinine (from 1.0 to 5.8 mg\/dL). She also has <strong>haemoptysis<\/strong> and bilateral pulmonary infiltrates on chest X-ray. Anti-GBM antibody is <strong>strongly positive<\/strong>. ANCA is negative. Renal biopsy shows <strong>crescents in 70% of glomeruli<\/strong> with linear IgG deposits on immunofluorescence. What is the diagnosis and the most critical treatment principle?',\n      correct: 'Anti-GBM disease (Goodpasture syndrome); immediate plasma exchange + immunosuppression before dialysis dependence',\n      opts: [\n        'Anti-GBM disease (Goodpasture syndrome); immediate plasma exchange + immunosuppression before dialysis dependence',\n        'ANCA-associated vasculitis (GPA); treat with IV cyclophosphamide alone',\n        'Lupus nephritis class IV with pulmonary involvement; high-dose steroids + MMF',\n        'IgA nephropathy with RPGN transformation; plasma exchange is not indicated'\n      ],\n      exp:     'The combination of <strong>pulmonary haemorrhage + rapidly progressive GN<\/strong> defines <strong>pulmonary-renal syndrome<\/strong>. <strong>Anti-GBM antibodies<\/strong> targeting the NC1 domain of type IV collagen confirm <strong>Goodpasture syndrome<\/strong>. Biopsy shows <strong>crescentic GN<\/strong> with <strong>linear IgG deposits<\/strong> on IF (vs granular in immune-complex GN; pauci-immune in ANCA vasculitis). Treatment is a medical emergency: <strong>plasma exchange<\/strong> (removes circulating anti-GBM antibody) + <strong>high-dose corticosteroids + cyclophosphamide<\/strong>. The crucial principle: if the patient is <em>already dialysis-dependent and anuric with &gt;85% crescents<\/em>, renal recovery is unlikely \u2014 plasma exchange is then deferred. But <strong>pulmonary haemorrhage remains an indication for plasma exchange even in anuric patients<\/strong>. Early aggressive treatment is the only chance at preserving renal function.',\n      imgId:   null\n    },\n\n    {\n      id:      5,\n      tag:     'Glomerular Disease &mdash; Lupus Nephritis',\n      stem:    'A <strong>28-year-old woman<\/strong> with known SLE develops worsening proteinuria (4.1 g\/day), haematuria, and creatinine rising to 2.2 mg\/dL. Anti-dsDNA titre is markedly elevated and C3 is low. Renal biopsy shows <strong>diffuse endocapillary proliferation in &gt;50% of glomeruli<\/strong> with subendothelial deposits and <strong>wire-loop lesions<\/strong>. What is the ISN\/RPS class and the preferred induction regimen?',\n      correct: 'Class IV (diffuse proliferative); mycophenolate mofetil + high-dose corticosteroids (or IV cyclophosphamide)',\n      opts: [\n        'Class IV (diffuse proliferative); mycophenolate mofetil + high-dose corticosteroids (or IV cyclophosphamide)',\n        'Class III (focal proliferative); hydroxychloroquine alone is sufficient',\n        'Class V (membranous); MMF monotherapy without steroids',\n        'Class II (mesangial proliferative); no immunosuppression required beyond baseline SLE therapy'\n      ],\n      exp:     '<strong>Wire-loop lesions<\/strong> (massive subendothelial immune deposits outlining capillary walls) and <strong>diffuse involvement (&ge;50% glomeruli)<\/strong> with endocapillary proliferation define <strong>ISN\/RPS Class IV \u2014 diffuse proliferative lupus nephritis<\/strong>. This is the most severe and the most common class seen in biopsy series. <strong>Induction therapy<\/strong>: either <strong>MMF (2\u20133 g\/day) + high-dose prednisolone<\/strong> or <strong>IV cyclophosphamide (NIH or Euro-Lupus protocol) + prednisolone<\/strong>. MMF is now preferred in most centres for non-severe cases (equivalent efficacy, less gonadotoxicity). <strong>Maintenance<\/strong>: MMF or azathioprine. Hydroxychloroquine should be continued throughout as it reduces flares and thrombosis risk. Low complement + high anti-dsDNA is the classic serological signature of active lupus nephritis.',\n      imgId:   'nep03-img5'\n    }\n\n  ];\n\n  var answers  = {};\n  var answered = 0;\n  var shuffled = {};\n  var done     = false;\n\n  function byId(id) { return document.getElementById(id); }\n  function gid(suffix) { return byId(NS + '-' + suffix); }\n\n  function shuffleArr(arr) {\n    var a = arr.slice(), i, j, tmp;\n    for (i = a.length - 1; i > 0; i--) {\n      j = Math.floor(Math.random() * (i + 1));\n      tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n    }\n    return a;\n  }\n\n  function countVal(val) {\n    var k, n = 0;\n    for (k in answers) {\n      if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n    }\n    return n;\n  }\n\n  function buildPips() {\n    var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n    cont.innerHTML = '';\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      if (i > 0) {\n        wLine = document.createElement('div');\n        wLine.className = 'mr-pip-wrap';\n        line = document.createElement('div');\n        line.className = 'mr-pip-line';\n        line.id = NS + '-pl' + q.id;\n        wLine.appendChild(line);\n        cont.appendChild(wLine);\n      }\n      wPip = document.createElement('div');\n      wPip.className = 'mr-pip-wrap';\n      pip = document.createElement('div');\n      pip.className = 'mr-pip';\n      pip.id = NS + '-pip' + q.id;\n      pip.textContent = String(q.id);\n      wPip.appendChild(pip);\n      cont.appendChild(wPip);\n    }\n  }\n\n  function build() {\n    var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n        rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n        optEl, ltrSpan, txtSpan;\n\n    cont = gid('cases');\n    cont.innerHTML = '';\n    answers = {}; answered = 0; shuffled = {}; done = false;\n    gid('score').style.display = 'none';\n    buildPips();\n\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      opts = shuffleArr(q.opts);\n      shuffled[q.id] = opts;\n\n      card = document.createElement('div');\n      card.className = 'mr-case';\n\n      top = document.createElement('div');\n      top.className = 'mr-case-top';\n\n      numDiv = document.createElement('div');\n      numDiv.className = 'mr-num';\n      numDiv.textContent = q.id < 10 ? 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