ACUTE NEPHRITIC SYNDROME
By Hakimah Khani Binti SuhaimiThird Year Medical Student
MARA University of Technology Malaysia
(this is the edited slides after discussions with Assoc Prof Dr Rashid =)
and bedsite teaching with Dr Faisal =)
Introductionbull Synonyms acute nephritis acute nephritic syndrome
bull An immunologic mechanism (Type III hypersensitivity) resulted from an immune process that injures the glomeruli of the kidney leading to reduced renal function characterized as follows
bull Clinical features ndash A sudden onset of hematuria ndash Proteinuriandash Edema ndash Oliguria and volume overloadndash Hypertension ndash Azotemia is another common but
inconstant finding
Glomerulo
nephritis
Acute Nephritic syndrome
Acute post strep GN
IgA Nephropath
y
MembranoProliferative
Henoch Schonlein Purpura
Alport Syndrome
SLE nephritis
Other post infectious glomerulonephritis
Nephrotic Syndrome
ACUTE POST-STREPTOCOCCAL GLOMERULONEPHRITIS
Outline
bull Definitionbull Epidemiologybull Etiology and Pathogenesisbull Clinical Featuresbull Complicationbull Investigationbull Diagnosisbull Differential Diagnosisbull Treatment and Managementbull Prognosis
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
Epidemiologybull 121 of the 124 patients had
poststreptococcal nephritis Department of Pediatrics HUSM July 1987- June 1988
bull Globally - incidence has decreased in the past three decades
bull Most commonly ndash sporadicbull Despite that epidemics and clusters of
cases - in some poor or rural communitiescopy 2008 American Society of Nephrology
bull Peak incidence - age 5-12 yo uncommon lt3yo
bull Male female ratio is 2 1Nelson Textbook of Pediatrics 7th Edition
VERY IMPORTANT TO REMEMBER TO EVALUATE THE
DX
Etiology and Pathogenesis
bull The child gets gets throat or skin infection by nephritogenic strain of group A beta hemolytic streptococci - serotype 12 4 and 1
bull Antibodies to streptoccocus (eg antistreptolysin O) are formed in his circulation
bull Antigen-antibody circulating immune complexes are subsequently deposited along the glomerular basement membrane (GBM)
Streptococcal infection
immune complex formation + deposited in GBM
complement system activated
immune injuries
cellular proliferation GBM fracture
capillary lumen narrowed hematuria
glomerular blood flow decreased proteinuria
oliguria GFR distal sodium reabsorption
activation of R-A-A-S retention of water amp sodium
blood volume
edema hypertension
Low serum complement
CLINICAL FEATURESStreptococcal pharyngitis Streptococcal impetigo
Typical Manifestation Develop acute nephritic syndrome 1ndash2 wk after an antecedent streptococcal pharyngitis or 3ndash6 wk after a streptococcal pyoderma
1 Edema75 of the patientsFace periorbital area lower extremities generalized (ascites pleural effusions)
2 Proteinuria ndash usu normalize after 4 weeks
3 Oliguriaschool child lt 400mldaypreschool child lt 300mldayinfant amp toddler lt 200mlday
co dyspneaopercussion stony dullnessoauscultation crepitations
Normal urine output of a childL 1-2mlkghour
Not as severe as nephrotic syndrome (only lt1gm2 day In nephrotic gt1gm2 day)
Typical Manifestation (2)3 Gross hematuria (65 of
patients)Smoky tea-colored cola-colored or fresh bloody urineMicroscopical hematuria (almost all patients)The urine appears normal but gt3 RBCsHP are found in centrifuged urine sediment examined microscopically
4 Hypertension (50) ndash mild to moderate typically subsides promptly after diuresis
5 Nonspecific symptoms Such as anorexia but with weight gain vomiting general malaise lethargy abdominal or flank pain amp low-grade fever
Donrsquot forget to ask about the symptoms of
hypertension in hx ok Blurred
vission Headache Dizziness
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
Meaning renal function restores after 5-10days
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Introductionbull Synonyms acute nephritis acute nephritic syndrome
bull An immunologic mechanism (Type III hypersensitivity) resulted from an immune process that injures the glomeruli of the kidney leading to reduced renal function characterized as follows
bull Clinical features ndash A sudden onset of hematuria ndash Proteinuriandash Edema ndash Oliguria and volume overloadndash Hypertension ndash Azotemia is another common but
inconstant finding
Glomerulo
nephritis
Acute Nephritic syndrome
Acute post strep GN
IgA Nephropath
y
MembranoProliferative
Henoch Schonlein Purpura
Alport Syndrome
SLE nephritis
Other post infectious glomerulonephritis
Nephrotic Syndrome
ACUTE POST-STREPTOCOCCAL GLOMERULONEPHRITIS
Outline
bull Definitionbull Epidemiologybull Etiology and Pathogenesisbull Clinical Featuresbull Complicationbull Investigationbull Diagnosisbull Differential Diagnosisbull Treatment and Managementbull Prognosis
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
Epidemiologybull 121 of the 124 patients had
poststreptococcal nephritis Department of Pediatrics HUSM July 1987- June 1988
bull Globally - incidence has decreased in the past three decades
bull Most commonly ndash sporadicbull Despite that epidemics and clusters of
cases - in some poor or rural communitiescopy 2008 American Society of Nephrology
bull Peak incidence - age 5-12 yo uncommon lt3yo
bull Male female ratio is 2 1Nelson Textbook of Pediatrics 7th Edition
VERY IMPORTANT TO REMEMBER TO EVALUATE THE
DX
Etiology and Pathogenesis
bull The child gets gets throat or skin infection by nephritogenic strain of group A beta hemolytic streptococci - serotype 12 4 and 1
bull Antibodies to streptoccocus (eg antistreptolysin O) are formed in his circulation
bull Antigen-antibody circulating immune complexes are subsequently deposited along the glomerular basement membrane (GBM)
Streptococcal infection
immune complex formation + deposited in GBM
complement system activated
immune injuries
cellular proliferation GBM fracture
capillary lumen narrowed hematuria
glomerular blood flow decreased proteinuria
oliguria GFR distal sodium reabsorption
activation of R-A-A-S retention of water amp sodium
blood volume
edema hypertension
Low serum complement
CLINICAL FEATURESStreptococcal pharyngitis Streptococcal impetigo
Typical Manifestation Develop acute nephritic syndrome 1ndash2 wk after an antecedent streptococcal pharyngitis or 3ndash6 wk after a streptococcal pyoderma
1 Edema75 of the patientsFace periorbital area lower extremities generalized (ascites pleural effusions)
2 Proteinuria ndash usu normalize after 4 weeks
3 Oliguriaschool child lt 400mldaypreschool child lt 300mldayinfant amp toddler lt 200mlday
co dyspneaopercussion stony dullnessoauscultation crepitations
Normal urine output of a childL 1-2mlkghour
Not as severe as nephrotic syndrome (only lt1gm2 day In nephrotic gt1gm2 day)
Typical Manifestation (2)3 Gross hematuria (65 of
patients)Smoky tea-colored cola-colored or fresh bloody urineMicroscopical hematuria (almost all patients)The urine appears normal but gt3 RBCsHP are found in centrifuged urine sediment examined microscopically
4 Hypertension (50) ndash mild to moderate typically subsides promptly after diuresis
5 Nonspecific symptoms Such as anorexia but with weight gain vomiting general malaise lethargy abdominal or flank pain amp low-grade fever
Donrsquot forget to ask about the symptoms of
hypertension in hx ok Blurred
vission Headache Dizziness
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
Meaning renal function restores after 5-10days
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Glomerulo
nephritis
Acute Nephritic syndrome
Acute post strep GN
IgA Nephropath
y
MembranoProliferative
Henoch Schonlein Purpura
Alport Syndrome
SLE nephritis
Other post infectious glomerulonephritis
Nephrotic Syndrome
ACUTE POST-STREPTOCOCCAL GLOMERULONEPHRITIS
Outline
bull Definitionbull Epidemiologybull Etiology and Pathogenesisbull Clinical Featuresbull Complicationbull Investigationbull Diagnosisbull Differential Diagnosisbull Treatment and Managementbull Prognosis
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
Epidemiologybull 121 of the 124 patients had
poststreptococcal nephritis Department of Pediatrics HUSM July 1987- June 1988
bull Globally - incidence has decreased in the past three decades
bull Most commonly ndash sporadicbull Despite that epidemics and clusters of
cases - in some poor or rural communitiescopy 2008 American Society of Nephrology
bull Peak incidence - age 5-12 yo uncommon lt3yo
bull Male female ratio is 2 1Nelson Textbook of Pediatrics 7th Edition
VERY IMPORTANT TO REMEMBER TO EVALUATE THE
DX
Etiology and Pathogenesis
bull The child gets gets throat or skin infection by nephritogenic strain of group A beta hemolytic streptococci - serotype 12 4 and 1
bull Antibodies to streptoccocus (eg antistreptolysin O) are formed in his circulation
bull Antigen-antibody circulating immune complexes are subsequently deposited along the glomerular basement membrane (GBM)
Streptococcal infection
immune complex formation + deposited in GBM
complement system activated
immune injuries
cellular proliferation GBM fracture
capillary lumen narrowed hematuria
glomerular blood flow decreased proteinuria
oliguria GFR distal sodium reabsorption
activation of R-A-A-S retention of water amp sodium
blood volume
edema hypertension
Low serum complement
CLINICAL FEATURESStreptococcal pharyngitis Streptococcal impetigo
Typical Manifestation Develop acute nephritic syndrome 1ndash2 wk after an antecedent streptococcal pharyngitis or 3ndash6 wk after a streptococcal pyoderma
1 Edema75 of the patientsFace periorbital area lower extremities generalized (ascites pleural effusions)
2 Proteinuria ndash usu normalize after 4 weeks
3 Oliguriaschool child lt 400mldaypreschool child lt 300mldayinfant amp toddler lt 200mlday
co dyspneaopercussion stony dullnessoauscultation crepitations
Normal urine output of a childL 1-2mlkghour
Not as severe as nephrotic syndrome (only lt1gm2 day In nephrotic gt1gm2 day)
Typical Manifestation (2)3 Gross hematuria (65 of
patients)Smoky tea-colored cola-colored or fresh bloody urineMicroscopical hematuria (almost all patients)The urine appears normal but gt3 RBCsHP are found in centrifuged urine sediment examined microscopically
4 Hypertension (50) ndash mild to moderate typically subsides promptly after diuresis
5 Nonspecific symptoms Such as anorexia but with weight gain vomiting general malaise lethargy abdominal or flank pain amp low-grade fever
Donrsquot forget to ask about the symptoms of
hypertension in hx ok Blurred
vission Headache Dizziness
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
Meaning renal function restores after 5-10days
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
ACUTE POST-STREPTOCOCCAL GLOMERULONEPHRITIS
Outline
bull Definitionbull Epidemiologybull Etiology and Pathogenesisbull Clinical Featuresbull Complicationbull Investigationbull Diagnosisbull Differential Diagnosisbull Treatment and Managementbull Prognosis
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
Epidemiologybull 121 of the 124 patients had
poststreptococcal nephritis Department of Pediatrics HUSM July 1987- June 1988
bull Globally - incidence has decreased in the past three decades
bull Most commonly ndash sporadicbull Despite that epidemics and clusters of
cases - in some poor or rural communitiescopy 2008 American Society of Nephrology
bull Peak incidence - age 5-12 yo uncommon lt3yo
bull Male female ratio is 2 1Nelson Textbook of Pediatrics 7th Edition
VERY IMPORTANT TO REMEMBER TO EVALUATE THE
DX
Etiology and Pathogenesis
bull The child gets gets throat or skin infection by nephritogenic strain of group A beta hemolytic streptococci - serotype 12 4 and 1
bull Antibodies to streptoccocus (eg antistreptolysin O) are formed in his circulation
bull Antigen-antibody circulating immune complexes are subsequently deposited along the glomerular basement membrane (GBM)
Streptococcal infection
immune complex formation + deposited in GBM
complement system activated
immune injuries
cellular proliferation GBM fracture
capillary lumen narrowed hematuria
glomerular blood flow decreased proteinuria
oliguria GFR distal sodium reabsorption
activation of R-A-A-S retention of water amp sodium
blood volume
edema hypertension
Low serum complement
CLINICAL FEATURESStreptococcal pharyngitis Streptococcal impetigo
Typical Manifestation Develop acute nephritic syndrome 1ndash2 wk after an antecedent streptococcal pharyngitis or 3ndash6 wk after a streptococcal pyoderma
1 Edema75 of the patientsFace periorbital area lower extremities generalized (ascites pleural effusions)
2 Proteinuria ndash usu normalize after 4 weeks
3 Oliguriaschool child lt 400mldaypreschool child lt 300mldayinfant amp toddler lt 200mlday
co dyspneaopercussion stony dullnessoauscultation crepitations
Normal urine output of a childL 1-2mlkghour
Not as severe as nephrotic syndrome (only lt1gm2 day In nephrotic gt1gm2 day)
Typical Manifestation (2)3 Gross hematuria (65 of
patients)Smoky tea-colored cola-colored or fresh bloody urineMicroscopical hematuria (almost all patients)The urine appears normal but gt3 RBCsHP are found in centrifuged urine sediment examined microscopically
4 Hypertension (50) ndash mild to moderate typically subsides promptly after diuresis
5 Nonspecific symptoms Such as anorexia but with weight gain vomiting general malaise lethargy abdominal or flank pain amp low-grade fever
Donrsquot forget to ask about the symptoms of
hypertension in hx ok Blurred
vission Headache Dizziness
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
Meaning renal function restores after 5-10days
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Outline
bull Definitionbull Epidemiologybull Etiology and Pathogenesisbull Clinical Featuresbull Complicationbull Investigationbull Diagnosisbull Differential Diagnosisbull Treatment and Managementbull Prognosis
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
Epidemiologybull 121 of the 124 patients had
poststreptococcal nephritis Department of Pediatrics HUSM July 1987- June 1988
bull Globally - incidence has decreased in the past three decades
bull Most commonly ndash sporadicbull Despite that epidemics and clusters of
cases - in some poor or rural communitiescopy 2008 American Society of Nephrology
bull Peak incidence - age 5-12 yo uncommon lt3yo
bull Male female ratio is 2 1Nelson Textbook of Pediatrics 7th Edition
VERY IMPORTANT TO REMEMBER TO EVALUATE THE
DX
Etiology and Pathogenesis
bull The child gets gets throat or skin infection by nephritogenic strain of group A beta hemolytic streptococci - serotype 12 4 and 1
bull Antibodies to streptoccocus (eg antistreptolysin O) are formed in his circulation
bull Antigen-antibody circulating immune complexes are subsequently deposited along the glomerular basement membrane (GBM)
Streptococcal infection
immune complex formation + deposited in GBM
complement system activated
immune injuries
cellular proliferation GBM fracture
capillary lumen narrowed hematuria
glomerular blood flow decreased proteinuria
oliguria GFR distal sodium reabsorption
activation of R-A-A-S retention of water amp sodium
blood volume
edema hypertension
Low serum complement
CLINICAL FEATURESStreptococcal pharyngitis Streptococcal impetigo
Typical Manifestation Develop acute nephritic syndrome 1ndash2 wk after an antecedent streptococcal pharyngitis or 3ndash6 wk after a streptococcal pyoderma
1 Edema75 of the patientsFace periorbital area lower extremities generalized (ascites pleural effusions)
2 Proteinuria ndash usu normalize after 4 weeks
3 Oliguriaschool child lt 400mldaypreschool child lt 300mldayinfant amp toddler lt 200mlday
co dyspneaopercussion stony dullnessoauscultation crepitations
Normal urine output of a childL 1-2mlkghour
Not as severe as nephrotic syndrome (only lt1gm2 day In nephrotic gt1gm2 day)
Typical Manifestation (2)3 Gross hematuria (65 of
patients)Smoky tea-colored cola-colored or fresh bloody urineMicroscopical hematuria (almost all patients)The urine appears normal but gt3 RBCsHP are found in centrifuged urine sediment examined microscopically
4 Hypertension (50) ndash mild to moderate typically subsides promptly after diuresis
5 Nonspecific symptoms Such as anorexia but with weight gain vomiting general malaise lethargy abdominal or flank pain amp low-grade fever
Donrsquot forget to ask about the symptoms of
hypertension in hx ok Blurred
vission Headache Dizziness
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
Meaning renal function restores after 5-10days
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
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
Epidemiologybull 121 of the 124 patients had
poststreptococcal nephritis Department of Pediatrics HUSM July 1987- June 1988
bull Globally - incidence has decreased in the past three decades
bull Most commonly ndash sporadicbull Despite that epidemics and clusters of
cases - in some poor or rural communitiescopy 2008 American Society of Nephrology
bull Peak incidence - age 5-12 yo uncommon lt3yo
bull Male female ratio is 2 1Nelson Textbook of Pediatrics 7th Edition
VERY IMPORTANT TO REMEMBER TO EVALUATE THE
DX
Etiology and Pathogenesis
bull The child gets gets throat or skin infection by nephritogenic strain of group A beta hemolytic streptococci - serotype 12 4 and 1
bull Antibodies to streptoccocus (eg antistreptolysin O) are formed in his circulation
bull Antigen-antibody circulating immune complexes are subsequently deposited along the glomerular basement membrane (GBM)
Streptococcal infection
immune complex formation + deposited in GBM
complement system activated
immune injuries
cellular proliferation GBM fracture
capillary lumen narrowed hematuria
glomerular blood flow decreased proteinuria
oliguria GFR distal sodium reabsorption
activation of R-A-A-S retention of water amp sodium
blood volume
edema hypertension
Low serum complement
CLINICAL FEATURESStreptococcal pharyngitis Streptococcal impetigo
Typical Manifestation Develop acute nephritic syndrome 1ndash2 wk after an antecedent streptococcal pharyngitis or 3ndash6 wk after a streptococcal pyoderma
1 Edema75 of the patientsFace periorbital area lower extremities generalized (ascites pleural effusions)
2 Proteinuria ndash usu normalize after 4 weeks
3 Oliguriaschool child lt 400mldaypreschool child lt 300mldayinfant amp toddler lt 200mlday
co dyspneaopercussion stony dullnessoauscultation crepitations
Normal urine output of a childL 1-2mlkghour
Not as severe as nephrotic syndrome (only lt1gm2 day In nephrotic gt1gm2 day)
Typical Manifestation (2)3 Gross hematuria (65 of
patients)Smoky tea-colored cola-colored or fresh bloody urineMicroscopical hematuria (almost all patients)The urine appears normal but gt3 RBCsHP are found in centrifuged urine sediment examined microscopically
4 Hypertension (50) ndash mild to moderate typically subsides promptly after diuresis
5 Nonspecific symptoms Such as anorexia but with weight gain vomiting general malaise lethargy abdominal or flank pain amp low-grade fever
Donrsquot forget to ask about the symptoms of
hypertension in hx ok Blurred
vission Headache Dizziness
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
Meaning renal function restores after 5-10days
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Epidemiologybull 121 of the 124 patients had
poststreptococcal nephritis Department of Pediatrics HUSM July 1987- June 1988
bull Globally - incidence has decreased in the past three decades
bull Most commonly ndash sporadicbull Despite that epidemics and clusters of
cases - in some poor or rural communitiescopy 2008 American Society of Nephrology
bull Peak incidence - age 5-12 yo uncommon lt3yo
bull Male female ratio is 2 1Nelson Textbook of Pediatrics 7th Edition
VERY IMPORTANT TO REMEMBER TO EVALUATE THE
DX
Etiology and Pathogenesis
bull The child gets gets throat or skin infection by nephritogenic strain of group A beta hemolytic streptococci - serotype 12 4 and 1
bull Antibodies to streptoccocus (eg antistreptolysin O) are formed in his circulation
bull Antigen-antibody circulating immune complexes are subsequently deposited along the glomerular basement membrane (GBM)
Streptococcal infection
immune complex formation + deposited in GBM
complement system activated
immune injuries
cellular proliferation GBM fracture
capillary lumen narrowed hematuria
glomerular blood flow decreased proteinuria
oliguria GFR distal sodium reabsorption
activation of R-A-A-S retention of water amp sodium
blood volume
edema hypertension
Low serum complement
CLINICAL FEATURESStreptococcal pharyngitis Streptococcal impetigo
Typical Manifestation Develop acute nephritic syndrome 1ndash2 wk after an antecedent streptococcal pharyngitis or 3ndash6 wk after a streptococcal pyoderma
1 Edema75 of the patientsFace periorbital area lower extremities generalized (ascites pleural effusions)
2 Proteinuria ndash usu normalize after 4 weeks
3 Oliguriaschool child lt 400mldaypreschool child lt 300mldayinfant amp toddler lt 200mlday
co dyspneaopercussion stony dullnessoauscultation crepitations
Normal urine output of a childL 1-2mlkghour
Not as severe as nephrotic syndrome (only lt1gm2 day In nephrotic gt1gm2 day)
Typical Manifestation (2)3 Gross hematuria (65 of
patients)Smoky tea-colored cola-colored or fresh bloody urineMicroscopical hematuria (almost all patients)The urine appears normal but gt3 RBCsHP are found in centrifuged urine sediment examined microscopically
4 Hypertension (50) ndash mild to moderate typically subsides promptly after diuresis
5 Nonspecific symptoms Such as anorexia but with weight gain vomiting general malaise lethargy abdominal or flank pain amp low-grade fever
Donrsquot forget to ask about the symptoms of
hypertension in hx ok Blurred
vission Headache Dizziness
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
Meaning renal function restores after 5-10days
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Etiology and Pathogenesis
bull The child gets gets throat or skin infection by nephritogenic strain of group A beta hemolytic streptococci - serotype 12 4 and 1
bull Antibodies to streptoccocus (eg antistreptolysin O) are formed in his circulation
bull Antigen-antibody circulating immune complexes are subsequently deposited along the glomerular basement membrane (GBM)
Streptococcal infection
immune complex formation + deposited in GBM
complement system activated
immune injuries
cellular proliferation GBM fracture
capillary lumen narrowed hematuria
glomerular blood flow decreased proteinuria
oliguria GFR distal sodium reabsorption
activation of R-A-A-S retention of water amp sodium
blood volume
edema hypertension
Low serum complement
CLINICAL FEATURESStreptococcal pharyngitis Streptococcal impetigo
Typical Manifestation Develop acute nephritic syndrome 1ndash2 wk after an antecedent streptococcal pharyngitis or 3ndash6 wk after a streptococcal pyoderma
1 Edema75 of the patientsFace periorbital area lower extremities generalized (ascites pleural effusions)
2 Proteinuria ndash usu normalize after 4 weeks
3 Oliguriaschool child lt 400mldaypreschool child lt 300mldayinfant amp toddler lt 200mlday
co dyspneaopercussion stony dullnessoauscultation crepitations
Normal urine output of a childL 1-2mlkghour
Not as severe as nephrotic syndrome (only lt1gm2 day In nephrotic gt1gm2 day)
Typical Manifestation (2)3 Gross hematuria (65 of
patients)Smoky tea-colored cola-colored or fresh bloody urineMicroscopical hematuria (almost all patients)The urine appears normal but gt3 RBCsHP are found in centrifuged urine sediment examined microscopically
4 Hypertension (50) ndash mild to moderate typically subsides promptly after diuresis
5 Nonspecific symptoms Such as anorexia but with weight gain vomiting general malaise lethargy abdominal or flank pain amp low-grade fever
Donrsquot forget to ask about the symptoms of
hypertension in hx ok Blurred
vission Headache Dizziness
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
Meaning renal function restores after 5-10days
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Streptococcal infection
immune complex formation + deposited in GBM
complement system activated
immune injuries
cellular proliferation GBM fracture
capillary lumen narrowed hematuria
glomerular blood flow decreased proteinuria
oliguria GFR distal sodium reabsorption
activation of R-A-A-S retention of water amp sodium
blood volume
edema hypertension
Low serum complement
CLINICAL FEATURESStreptococcal pharyngitis Streptococcal impetigo
Typical Manifestation Develop acute nephritic syndrome 1ndash2 wk after an antecedent streptococcal pharyngitis or 3ndash6 wk after a streptococcal pyoderma
1 Edema75 of the patientsFace periorbital area lower extremities generalized (ascites pleural effusions)
2 Proteinuria ndash usu normalize after 4 weeks
3 Oliguriaschool child lt 400mldaypreschool child lt 300mldayinfant amp toddler lt 200mlday
co dyspneaopercussion stony dullnessoauscultation crepitations
Normal urine output of a childL 1-2mlkghour
Not as severe as nephrotic syndrome (only lt1gm2 day In nephrotic gt1gm2 day)
Typical Manifestation (2)3 Gross hematuria (65 of
patients)Smoky tea-colored cola-colored or fresh bloody urineMicroscopical hematuria (almost all patients)The urine appears normal but gt3 RBCsHP are found in centrifuged urine sediment examined microscopically
4 Hypertension (50) ndash mild to moderate typically subsides promptly after diuresis
5 Nonspecific symptoms Such as anorexia but with weight gain vomiting general malaise lethargy abdominal or flank pain amp low-grade fever
Donrsquot forget to ask about the symptoms of
hypertension in hx ok Blurred
vission Headache Dizziness
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
Meaning renal function restores after 5-10days
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
CLINICAL FEATURESStreptococcal pharyngitis Streptococcal impetigo
Typical Manifestation Develop acute nephritic syndrome 1ndash2 wk after an antecedent streptococcal pharyngitis or 3ndash6 wk after a streptococcal pyoderma
1 Edema75 of the patientsFace periorbital area lower extremities generalized (ascites pleural effusions)
2 Proteinuria ndash usu normalize after 4 weeks
3 Oliguriaschool child lt 400mldaypreschool child lt 300mldayinfant amp toddler lt 200mlday
co dyspneaopercussion stony dullnessoauscultation crepitations
Normal urine output of a childL 1-2mlkghour
Not as severe as nephrotic syndrome (only lt1gm2 day In nephrotic gt1gm2 day)
Typical Manifestation (2)3 Gross hematuria (65 of
patients)Smoky tea-colored cola-colored or fresh bloody urineMicroscopical hematuria (almost all patients)The urine appears normal but gt3 RBCsHP are found in centrifuged urine sediment examined microscopically
4 Hypertension (50) ndash mild to moderate typically subsides promptly after diuresis
5 Nonspecific symptoms Such as anorexia but with weight gain vomiting general malaise lethargy abdominal or flank pain amp low-grade fever
Donrsquot forget to ask about the symptoms of
hypertension in hx ok Blurred
vission Headache Dizziness
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
Meaning renal function restores after 5-10days
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Typical Manifestation Develop acute nephritic syndrome 1ndash2 wk after an antecedent streptococcal pharyngitis or 3ndash6 wk after a streptococcal pyoderma
1 Edema75 of the patientsFace periorbital area lower extremities generalized (ascites pleural effusions)
2 Proteinuria ndash usu normalize after 4 weeks
3 Oliguriaschool child lt 400mldaypreschool child lt 300mldayinfant amp toddler lt 200mlday
co dyspneaopercussion stony dullnessoauscultation crepitations
Normal urine output of a childL 1-2mlkghour
Not as severe as nephrotic syndrome (only lt1gm2 day In nephrotic gt1gm2 day)
Typical Manifestation (2)3 Gross hematuria (65 of
patients)Smoky tea-colored cola-colored or fresh bloody urineMicroscopical hematuria (almost all patients)The urine appears normal but gt3 RBCsHP are found in centrifuged urine sediment examined microscopically
4 Hypertension (50) ndash mild to moderate typically subsides promptly after diuresis
5 Nonspecific symptoms Such as anorexia but with weight gain vomiting general malaise lethargy abdominal or flank pain amp low-grade fever
Donrsquot forget to ask about the symptoms of
hypertension in hx ok Blurred
vission Headache Dizziness
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
Meaning renal function restores after 5-10days
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Typical Manifestation (2)3 Gross hematuria (65 of
patients)Smoky tea-colored cola-colored or fresh bloody urineMicroscopical hematuria (almost all patients)The urine appears normal but gt3 RBCsHP are found in centrifuged urine sediment examined microscopically
4 Hypertension (50) ndash mild to moderate typically subsides promptly after diuresis
5 Nonspecific symptoms Such as anorexia but with weight gain vomiting general malaise lethargy abdominal or flank pain amp low-grade fever
Donrsquot forget to ask about the symptoms of
hypertension in hx ok Blurred
vission Headache Dizziness
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
Meaning renal function restores after 5-10days
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
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
Meaning renal function restores after 5-10days
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Complications in severe cases
bull Circulatory hypervolemia Congestive heart failure
bull Encephalopathy
bull Acute renal failure
Sx Distended JVP dyspnea
Sx blurred vision confusion coma
headache
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Laboratory Investigations1 Urinalysis2 Bacteriological and Serological
test3 Renal function test4 Full blood count5 Serum complement levels6 Kidney ultrasound
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Laboratory Investigations
Urinalysisbull Macroscopic hematuria Rusty or tea-colorbull Microscopy leukocytes red blood cell casts
(pathognomonic) and granular casts bull Proteinuria 2+ (Nephrotic-range proteinuria
occurs in lt5 of patients) bull Pyuria The urine contains large amounts of
fibrin degradation products and fibrinopeptidesWhy I say itrsquos pathognomonic Hehee because in some
other cases there may be red urine + positive blood on dipstick and microscopy but there will BE NO RBC
CASTS FOUND It suggests that there is a urinary tract bleeding from a site beyond the renal tubules Still
however if there is no casts we canrsquot exclude a glomerular etiology
Read more in Nelson page 757 interestingggg =)
Defined as gt3-5 RBCs per high power field
in a freshly voided and centrifuged urine
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Laboratory Investigations
bull Evidences of streptococcal infection ndash Throat or skin cultures ndash Antistreptolysin O (ASO) titer Pharyngitis (80)
skin infections (lt50) ndash Anti-deoxyribonuclease (DNase) B level
Pharyngitis (98) skin infections (80) bull Renal function Test
ndash 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
ndash Hyperkalemia hypocalcaemia hyponatremia and metabolic acidosis are seen only in severe patients
NOT DONE IN MSIA Not needed anyway If nak buat
jugak pi try dkt spore
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
(side note)
bull Treatment of Hyperkalemia1 Insulin + glucose (will cause
transcellular shift of K+ into the cell)
2 Sodium bicarbonate3 Calcium gluconate (as a
cardioprotective agentThough it does not have an effect on potassium levels in the blood it reduces the excitability of cardiomyocytes thus lowering the likelihood of developing cardiac
arrhythmias)ndash IV slow infusion4 Chelating agent5 Lastly consider dialysis
(peritoneal dialysis in children)
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Laboratory Investigations
bull Full Blood Countndash A mild normochromic anemia may be
present from hemodilution and low-grade hemolysis
ndash Leococytosis maybe present
bull Activation of complementsndash Serum C3 level decrease (90) return to
normal within 6 weeks ndash Serum C4 levels are typically normal
bull Kidney ultrasoundndash Not necessary if patient has clear cut acute
nephritic syndrome
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Renal Biopsy
bull Patients whose clinical presentation laboratory findings or course is atypical
bull Delay resolutiono oliguria gt 2 weekso Azotaemia gt 3 weekso Gross haematuria gt 3 weekso Persistent proteinuria gt 6 months
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Light microscopeNot specific for post streptococcal nephritis
bullGlomeruli appear enlarged and hypercellular bullDiffuse mesangial cell proliferation with an increase in mesangial matrix
bullPolymorphonuclear leukocytes are common in glomeruli during the early stage of the disease
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Electron microscope
bullSubepithelial electron-dense deposits or ldquohumpsrdquo are present which are observed on the epithelial side of the glomerular basement membrane (GBM)
bullGaps or discontinuities of GBM which is likely indicative of proteinuria and hematuria
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Immunofluorescence microscopy
bullLumpy-bumpy deposits of immunoglobulin G and complement 3 along the capillary loops and within the mesangium
bullIt is helpful in the differential diagnosis of other entities that may mimic APSGN clinically particularly IgA nephropathy
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Diagnosis
bull Acute onsetbull Symptoms edema oliguria dark
urine hypertensionbull Urinalysis RBCs protein castsbull Evidences of streptococcal
infectionndash Prodromesndash Elavated serum titers of Abs to
streptozymes(ASO)bull Serum C3 - Reduced
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Differential DiagnosisPoints to support Points against
Membrano-proliferative GN
a) Nephritic syndrome
b) Elevated ASO titer
c) Hypocomplement-emia
a) Persistent nephritic syndromeb) Hypocomplementemia (C3) -
gt6-8wc) Marked reduced renal fnd) Dx ndash by renal biopsy ndash ldquotram-
trackingrdquo GBM
IgA nephropathy (Bergerrsquos disease)
a) Hematuriab) Associated with
respiratory illness (following viral syndromes)
a) Recurrentb) No period of latencyc) Hypertension amp edema ndash
uncommond) ASO ndash not elevatede) uarr Serum IgA (15)f) Normal serum complement
valuesg) Focal proliferation diffuse
mesangial IgA deposits
Henoch- Schoumlnlein Purpura
a) Hematuria (80)
b) Mild proteinuriac) Preceding by
URTI (only 50)
a) Characteristic skin rashb) Assoc symptoms Abdominal
pain diarrhea (due to intussusceptions) athritis athralgia
c) Normal serum complement values
copy Hakimah
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Differential DiagnosisPoints to support Points against
Familial nephritis (Alport Syndrome)
a) Nephritic syndromeb) 1-2 days following
URTI
a) Lack of expected complete resolution
b) Progressive proteinuria after 2nd decade of life
c) Association with non-renal manifestations hearing deficits amp ocular abnormalities
SLE nephritis(Nephritic- Grade I amp II Nephrotic- Grade III)
a) Occurs in 30ndash70 of children
b) Hematuriac) Mild proteinuriad) Hypocomplement-
emia (C3)
a) Lack of expected complete resolution
b) Association with non-renal manifestations
c) C4 also depressedd) Detection of anti-nuclear
antibodies
Other chronic infections
a) Acute nephritic syndrome
b) Similar histopathologic findings
c) Hypocomplementemia
a) Missing evidence of a prior streptococcal infection
b) Treatment is unresponsive
copy Hakimah
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Some other differential diagnosis ldquovomitedrdquo by the medical students were
1 AllergicApart from swelling + rashes in history takingbull Any shortness of breathbull Any itchinessbull Any history of allergybull Any family history of allergy
2 Nephrotic syndrome (the ones with hematuria Homework =P)3 Rheumatic fever
bull Meet the Jones criteria
Additional notes after bedsite with dr faisal
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Treatment
bull Treatment of APSGN is largely that of supportive care
bull Usually patients undergo a spontaneous diuresis within 7 to 10 days after the onset of their illness - strict monitoring ndash nephrotic chart + fluid restriction until diuresis
bull Management is directed at treating the acute effects of renal insufficiency and hypertension
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
bull Diuretics
bull DietFluid restrictionndash during oliguric phaseSodium restriction is necessaryProtein restriction is unnecessary
bull AntibioticsA 10-day course of systemic antibiotic therapy with penicillin V is recommended to limit the spread of the nephritogenic organismsAntibiotic therapy does not affect the natural history of glomerulonephritis
Paediatric Protocols 12th Edition
Due to renal insufficiency
Post strep GN is a sequelae after 2-
3weeks (not antigen-mediated but immune-mediated) Hence the
need to administer antibiotic to get rid of
any strep left and prevent further
immune-mediated cx
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Treatment for complications
Bed rest
Recheck BP frac12 hour later
Oral nifedipine
Add
Furosemide
Other oral AHT
Significant asymptomatic hypertension
Look for signs and symptoms
Emergency management
indicated
Target BP control
Reduce BP by 25 of target BP
over 3-12 hrs
Next reduction of 75 over 48
hrs
symptomatic severe hypertension or hypertensive emergency encephalopathy
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Treatment for complications
-Give O2
-prop patient up
-ventilatory support if necessary
IV
furosemide
Fluid restriction
-withhold fluid for 24 Hrs if possiible
Consider dialysis if no response to diuretics
Acute pulmon
ary edema
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Treatment for complications
Monitor BP amp managing
hypertension
Limiting fluid intake in
oliguric state
Correcting electrolyte imbalance
ie life threatening hyperkalemi
a
Optimizing nutritional intake
(since ARF pt usually hypercatabolic)
Implementing acute dialysis
Acute Renal Failure
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Follow-up
bull for at least 1 yearbull monitor BP at every visitbull do urinalysis and renal func1048991 onto evaluate recoverybull repeat C3 levels 6 weeks later if
not already normalised by time of discharge
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition
Prognosis
bull short term outcome excellent mortality lt05
bull long term outcome 18 of children develop chronic kidney disease
bull following post streptococcal AGN These children should be referred to the paediatric nephrologists for further evaluation and management
Paediatric Protocols 12th Edition