Acute Glomerulonephritis

Assoc. Prof. Suwannee Wisanuyotin

Department of Pediatrics, KKU

Objectives

◼ Etiology of AGN in children

◼ APSGN

➢ Etiology

➢ Epidemiology

➢ Pathogenesis

➢ Clinical manifestations

➢ Investigatios

➢ Treatment

➢ Prognosis

AGN

Acute inflammation of glomeruli

(mostly immunologic process)

Edema, oliguria, HTN, hematuria, proteinuria, azotemia

Etiology

Common

-Post infectious GN

APSGN

Other systemic infections

Etiology (cont.)

Less common

-HSP

-MPGN

-IgA nephropathy

-SLE

-Familial nephritis

-IE-related

-Shunt nephritis

Etiology (cont.)

Uncommon

-Wegener’s granumatosus

-Polyarteritis nodosa

Acute Post-streptococcal Glomerulonephritis

(APSGN)

Etiology

-Gr A β-hemolytic streptococcus

(nephritogenic strain)

-Pharyngitis, pyoderma

Epidemiology

-Age 2-12 yr (esp. 5-6 yr)

-M : F = 1.7-2:1

-Sporadic, epidemic

-Crowd, poor hygiene, malnutrition,

anemia, parasitic infestation

Pathogenesis

Streptococcal infectionLatent period

Immune-mediated process

Complement activation

PathophysiologyCell proliferation in glomeruli -Proteinuria

-Hematuria

Capillary lumen obliteration

GFR

Salt & water retention Waste product retention

Edema HTN Oliguria Azotemia

Clinical Manifestations

Hematuria 100%

Proteinuria 80%

Edema 90%

Hypertension 60-80%

Oliguria 10-50%

CHF <5%

NS 4%

Azotemia 25-40%

Urinalysis

-High urine sp.gr. & osmole

-Mild to moderate proteinuria

-Dysmorphic rbc esp. acanthocyte

-Hyaline, granular, rbc casts

CBC & Blood Chemistry

-NCNC anemia

-Normal wbc & platelet count

( platelet count :rare)

- BUN & Cr ( GFR > 50%)

-Hyponatremia (rare)

Evidence of Streptococcal Infection

-Antibody : ASO, antiDNase B, AHT,

anti NADase, antistreptolysin

-Culture : TSC, pus C/S

Complement

- CH50, C3 (6-8 wks)

- Normal C4

AGN : Low C3

- Acute postinfectious GN

- LN

- MPGN

- SBE

- Shunt nephritis

AGN : Normal C3

- HSP

- IgA nephropathy

- Idiopathic RPGN

- Wegener’s granulomatosis

Differential Diagnosis

- LN

- MPGN

- HSP

- IgA nephropathy

- RPGN

Indication for admission

- Severe hypertension

- Severe edema

- Dyspnea, orthopnea

- Renal failure

- Anuria

Treatment

- Bed rest : esp. in HTN, dyspnea, gross

hematuria

- Water : IL + UO

Treatment (cont.)

- Diet

Energy : RDA

Salt : < 1/3 – 1/2 of maintenance

Na+

Protein : restriction if renal failure

Potassium : restriction if renal failure

or severe oliguria

Treatment (cont.)

- Drugs

Diuretics : Furosemide

X Mannitol

Antihypertensive drugs :

hydralazine, CCB

hypertensive encephalopathy →

Nicardipine, labetalol,

sodium nitroprusside

Treatment (cont.)

◼ Drugs

Antibiotics : Pen V, amoxycillin,

erythromycin if TSC or pus C/S +

X Prednisolone

Clinical Course

- Recovery in 7-10 d ( urine, edema,

HTN, BUN & Cr)

- Gross hematuria 2-3 wks

- Normalized C3 in 6-8 wks

- Proteinuria 3-6 mo

- Microscopic hematuria 1-2 yr

Kidney biopsy

X Typical APSGN

Severe disease (NS, RPGN)

Atypical APSGN

Prognosis

- CRF < 2%

- Recurrence < 0.7-7%

- Poor prognostic factors

Adult onset

RPGN

NS

Avoid vigorous exercise 1 yr

References

◼ Pediatric Nephrology. 7th ed.

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