Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint:
This section will vary depending on the severity of IgA nephropathy. Common complaints may include:
Hematuria (blood in the urine) – painless, gross or microscopic
No or minimal other symptoms (early stages)
Proteinuria (excess protein in the urine) – may be detected on routine testing
Fatigue, high blood pressure, or swelling (in advanced stages)
History of Present Illness:
Age at onset of symptoms (often young adults)
Duration and frequency of hematuria (gross or microscopic)
Presence of other urinary symptoms (urgency, frequency)
History of infections (potential triggers)
Family history of kidney disease
Past Medical History:
Underlying medical conditions (e.g., hypertension, liver disease)
Prior surgeries or procedures
History of medications (including over-the-counter)
Family History:
Family history of IgA nephropathy (uncommon)
Family history of kidney disease
Social History:
Current medications and supplements
Smoking history (may worsen kidney function)
Alcohol or drug use
Recent travel history (potential exposure to infections)
Physical Examination:
Vital signs (may be normal or show signs of high blood pressure)
General examination: signs of fluid overload (edema) – uncommon in early stages
Abdominal exam: may reveal enlarged kidneys (uncommon)
Laboratory Tests:
Urinalysis:
Hematuria (red blood cells)
Proteinuria (elevated protein-to-creatinine ratio)
Blood tests:
Kidney function tests (eGFR): to assess kidney function
Electrolytes: to assess for imbalances
Serum IgA levels: may be elevated but not diagnostic
Imaging Studies:
Ultrasound of the kidneys: to assess kidney size and structure
Optional: Intravenous pyelography (IVP) or renal angiography (may be used in specific situations)
Kidney Biopsy:
Considered the gold standard for diagnosis, especially if other causes are suspected.
Not always necessary if clinical presentation and laboratory findings are highly suggestive.
Diagnosis:
IgA Nephropathy: Based on clinical presentation (hematuria), proteinuria, and kidney function tests, with possible confirmation by kidney biopsy.
Staging (optional):
Some classification systems stage IgA nephropathy based on the severity of proteinuria and kidney function.
Treatment Plan:
Treatment approach depends on the severity of proteinuria, kidney function, and blood pressure control.
Lifestyle modifications:
Healthy diet (low salt, low protein may be recommended in some cases)
Exercise
Smoking cessation
Weight management
Medications:
Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) – to control blood pressure and slow disease progression.
Other medications to manage proteinuria or high cholesterol (if present).
Immunosuppressive medications: May be considered in severe cases or those not responding to other therapies.
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of proteinuria, kidney function, and response to treatment.
IgA nephropathy can have a variable course.
Early diagnosis and treatment can help slow disease progression and prevent kidney failure.
Regular follow-up is crucial to monitor kidney function, proteinuria, and blood pressure.
Patient Education:
Importance of following the prescribed treatment plan, including lifestyle modifications and medications.
Importance of regular follow-up appointments for monitoring kidney function.
Recognizing signs of worsening kidney function (fatigue, decreased urine output, swelling).
Support groups and resources for patients with IgA nephropathy.
Next Follow-up:
Schedule for the next appointment depends