3. Glomerular disease includes
glomerulonephritis, i.e. inflammation of
the glomeruli and glomerulopathies when
there is no evidence of inflammation.
Glomerulonephritis is a subset of
glomerulopathies
4.
5. Acute glomerulonephritis (AGN) is an
abrupt onset of one or more features of an
Acute Nephritic Syndrome :
• Oedema e.g. facial puffiness
• Microscopic / macroscopic haematuria
• Decreased urine output (oliguria)
• Hyprtension
• Azotemia
Acute Glomerulonephritis
6. Presenting features of AGN
Acute nephritic syndrome (most common)
Nephrotic syndrome
Rapidly progressive glomerulonepritis
Hypertensive encephalopathy
Pulmonary oedema
Subclinical (detected on routine
examination)
7. Causes of Acute Nephritis
Post streptococcal AGN
Post-infectious acute glomerulonephritis (other
than Grp A B-Haemolytic Stretococci)
Subacute bacterial endocarditis
Henoch- Schoelein Purpura
IgA nephropathy
Hereditary nephritis
SLE
Systemic vasculitis
9. In children, the commonest cause of acute
nephritic syndrome is post-infectious
AGN, mainly due to post-streptococcal
infection of the pharynx or skin.
Post streptococcal AGN is commonest at
6-10 years age.
11. Definition
AGN that follows an infection with a
nephritogenic strain of group A beta
hemolytic streptococci.
The classic example of the acute nephritic
syndrome.
Nelson Textbook of Pediatrics, 7th
Edition
14. Etiology and
pathogEnEsis
The child gets throat or skin infection by nephritogenic
strain of group A beta hemolytic streptococci - serotype
12 , 4 and 1
Antibodies to streptoccocus (eg antistreptolysin O) are
formed in the circulation
Antigen-antibody circulating immune complexes are
subsequently deposited along the glomerular basement
membrane (GBM).
17. typical manifEstation
Develop acute nephritic syndrome 1–2 wk after an antecedent
streptococcal pharyngitis or 3–6 wk after a streptococcal
pyoderma.
1.Edema
75% of the patients
Face, periorbital area lower extremities generalized
(ascites, pleural effusions)
2. Proteinuria – usually normalize after 4 weeks
3. Oliguria
school child < 400ml/day
preschool child < 300ml/day
infant & toddler < 200ml/day
18. typical manifEstation
3. Gross hematuria (65% of patients)
Smoky, tea-colored, cola-colored, or fresh bloody urine
Microscopical hematuria (almost all patients)
The urine appears normal, but >3 RBCs/HP are found in
centrifuged urine sediment examined microscopically.
4. Hypertension (50%) – mild to moderate, typically
subsides promptly after diuresis
5. Nonspecific symptoms:
Such as anorexia, vomiting, general malaise, lethargy,
abdominal or flank pain, low-grade fever and weight
gain.
19.
20. Clinical course
Spontaneous improvement typically begins within 1 wk
with resolution of edema in 5-10 days and hypertension
in 2-3 wk, but urinalysis may be abnormal (persistent
microscopic hematuria) for a year.
21. invEstigations
Urinalysis and culture
• Haematuria – present in all patients.
• Proteinuria (trace to 2+, but may be in the
nephrotic range; usually associated with more
severe disease.)
• Red blood cell casts (pathognomonic of acute
glomerulonephritis).
• Other cellular casts.
• Pyuria may also be present.
22. invEstigations
Bacteriological and serological evidence of antecedent
streptococcal infection:
• Raised ASOT ( > 200 IU/ml ).
• Increased anti-DNAse B (if available) – a
better serological marker of preceding
streptococcal skin infection.
• Throat swab or skin swab.
Renal function test
• The BUN concentration is elevated in 75% of patients, and
serum creatinine level is increased in one half of the patients, but
profound decrease in GFR is uncommon in children.
• Hyperkalemia, hypocalcaemia, hyponatremia, and metabolic
acidosis are seen only in severe patients.
23. InvestIgatIons
Full blood count
• A mild normochromic anemia may be present from
hemodilution and low-grade hemolysis.
• Leucocytosis may be present.
Complement levels
• C3 level – low at onset of symptoms, normalizes by 6wks
• C4 is usually within normal limits in post-streptococcal
AGN.
Ultrasound of the kidneys
• Not necessary if patient has clear cut acute nephritic
syndrome.
24. IndIcatIons for
renal
BIopsy
Severe acute renal failure requiring dialysis.
Features suggesting non post-infectious AGN as the
cause of acute nephritis.
Delayed resolution
• Oliguria > 2 weeks
• Azotaemia > 3 weeks
• Gross haematuria > 3 weeks
• Persistent proteinuria > 6 months
25. lIght mIcroscope
not specIfIc for post streptococcal nephrItIs
•Glomeruli appear enlarged and hypercellular.
•Diffuse mesangial cell proliferation with an increase in mesangial
matrix.
•Polymorphonuclear leukocytes are common in glomeruli during
the early stage of the disease.
26. dIagnosIs
Acute onset
Symptoms: edema, oliguria, dark urine,
hypertension
Urinalysis: RBCs, protein, casts
Evidences of streptococcal infection:
– Prodromes
– Elavated serum titers of Abs to
streptozymes(ASO)
Serum C3 - Reduced
29. management
Strict monitoring - fluid intake, urine output,
daily weight, BP (Nephrotic chart)
Penicillin V for 10 days to eliminate β -
haemolytic streptococcal infection (give
erythromycin if penicillin is contraindicated)
Fluid restriction to control oedema and
circulatory overload during oliguric phase
until child diureses and blood pressure is
controlled
30. management
• Day 1 : up to 400 mls/m²/day. Do not administer
intravenous or oral fluids if child has pulmonary
oedema.
• Day 2 : till patient diureses – 400 mls/m²/day (as long
as patient remains in circulatory overload)
• When child is in diuresis – free fluid is allowed
Diuretic (e.g. Frusemide) should be given in
children with pulmonary oedema. It is also
usually needed for treatment of hypertension.
Diet – no added salt to diet. Protein restriction is
unnecessary
31. complIcatIons
Look out for complications of post-
streptococcal AGN:
• Hypertensive encephalopathy usually
presenting with seizures
• Pulmonary oedema (acute left ventricular
failure)
• Acute renal failure
34. Prehypertension is defined as a blood pressure
in at least the 90th percentile, but less than the
95th percentile, for age, sex, and height, or a
measurement of 120/80 mm Hg or greater.
Hypertension is defined as blood pressure in
the 95th percentile or greater.
38. follow-up
For at least 1 year.
Monitor BP at every visit
Do urinalysis and renal function to
evaluate recovery.
Repeat C3 levels 6 weeks later if not
already normalised by the time of
discharge.
39. ouTcoME
Short term outcome: Excellent, mortality
<0.5%.
Long term outcome: 1.8% of children
develop chronic kidney disease following
post streptococcal AGN.
These children should be referred to the
paediatric nephrologists for further
evaluation and management.
Normal histological structure of a glomerulus. On the right, is a 3-D illustration of a glomerulus.
Left one shows AA = affrent arteriole, EA= Efferent arteriole, BC= Bowman’s capsule, US= Urinary space
