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ACUTE GLUMEROLUNEPHRITIS BASICS DESCRIPTION An immunologic response to an infection (usually streptococcal) which damages the renal glomeruli.

It can be initiated by other bacterial and viral infections. This is an immune complex, hypocomplementemic glomerulonephritis. Most common in children. Characterized by diffuse inflamatory changes in the glomeruli and clinically by the abrupt onset of hematuria with red blood cell casts, and mild proteinuria. Accompanied in many cases by hypertension, edema, and azotemia. System(s) affected: Renal/Urologic Genetics: No known genetic pattern Incidence/Prevalence in USA: 20/100,000/ year (1-2% of pyodermas and 8% of streptococcal infections in children; occurs with impetigo in the late summer and with streptococcal pharyngitis in the winter) Predominant age: 60% of cases in children 2-12 years old Only 10% older than 40 years of age Predominant sex: Male > Female (60:40) SIGNS & SYMPTOMS Classic findings of acute nephritis Hematuria (100%) Oliguria or anuria (52%) Edema (85%) Hypertension (82%) Hypocomplementemia (C3) (83%) Gross hematuria (30%), tea-colored urine Edema of face and eyes in the mornings and feet and ankles in the afternoons and evenings Fever (rare) Other signs and symptoms Pharyngitis Respiratory infection Scarlet fever Dark urine Weight gain Abdominal pain Anorexia Back pain Pallor Impetigo CAUSES Follows group A beta-hemolytic streptococcus infection Nephritogenic strains of strep - groups 1, 4, 11, 12, 49 Red Lake, 55, 60 Unusual to have a second attack - protective immunity to nephritogenic antigen Cases of postinfective glomerulonephritis have also been reported from pneumococcus, staphylococcus, meningococcus, chickenpox, and hepatitis Streptococcal infection precedes renal lesions by 1-3 weeks Pharyngitis precedes renal lesions by 1-2 weeks (types 1, 2, 4, 12) Impetigo - (types 49, 55, 57) usually precedes throat or otitis media infection by 2-4 weeks RISK FACTORS 15% occurrence rate after infection with nephritogenic strain Endemic with cyclic epidemics Subclinical cases 20 times more common Streptococcal infection (e.g., scarlet fever or erysipelas) can be associated with rheumatic fever or acute glomerulonephritis, rarely both

DIAGNOSIS

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DIFFERENTIAL DIAGNOSIS Membranoproliferative glomerulonephritis Other postinfective glomerulonephritis Systemic lupus erythematosus IgA nephropathy Anaphylactoid purpura Rapidly progressive glomerulonephritis LABORATORY Streptococcal tests (Streptozyme) that include many antigens are most sensitive (+ or -) for screening but not quantitative Antistreptolysin O (ASO) - quantitative titer. Increased in 60-80% of cases. Increase begins 1-3 weeks, is highest 3-5 weeks, normal in 6 months. ASO titer is unrelated to severity, duration or prognosis of renal disease. Red blood cells casts on urinalysis: destroyed by centrifugation disintegrate in urine, particularly alkaline urine Characteristically, red blood cells from glomerular bleeding are distorted while those from lower urinary tract have normal morphology U/P creatinine > 40, decreased renin Culture throat and skin lesions for streptococcus C3 and C4 complements are best for evaluation Streptozyme Hypertriglyceridemia Proteinuria Decreased glomerular filtration rate Uremia Increased serum creatinine Anemia ANA to rule out systemic lupus erythematosus Drugs that may alter lab results: N/A Disorders that may alter lab results: N/A PATHOLOGICAL FINDINGS On renal biopsy Diffuse proliferative and exudative glomerulonephritis Electron microscopy - subepithelial deposits Immunofluorescence - C3 in almost all cases, some with IgG and IgM SPECIAL TESTS N/A IMAGING X-rays and/or ultrasound are not necessary to make the diagnosis DIAGNOSTIC PROCEDURES If progressive, consider renal biopsy. Biopsy usually not indicated. TREATMENT APPROPRIATE HEALTH CARE Most patients can be safely followed as outpatients Inpatient usually until blood pressure and creatinine normalized and edema begins to recede GENERAL MEASURES Decrease salt: no-added salt diet until edema and hypertension clear Decrease fluids to insensible losses plus 2/3 of the urine output until diuresis Control hypertension with diuretics Dialysis: peritoneal dialysis or hemodialysis for symptomatic azotemia, unresponsive hyperkalemia, intractable acidosis, diuretic resistant pulmonary edema SURGICAL MEASURES N/A ACTIVITY Can return to full activity after clinically improved. May have increased hematuria after exercise for up to two years. DIET No-added salt diet until edema, hypertension, and azotemia clear Restrict protein in presence of azotemia and metabolic acidosis Avoid high potassium foods PATIENT EDUCATION

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National Kidney Foundation, 30 E. 33rd Street, Suite 1100, New York, NY 10016, (212)889-2210 Web site - www.healthanswers.com MEDICATIONS DRUG(S) OF CHOICE Hyperkalemia No potassium in IV fluids until hyperkalemia resolves Sodium polystyrene sulfonate (Kayexalate) resin: 1 gm/kg in 10% sorbitol, pr or po If acidosis present, treat as indicated below Hypocalcemia with symptomatic hyperkalemia: 0.5 cc/kg 10% calcium gluconate IV over 30 minutes Hypocalcemia with asymptomatic hyperkalemia: oral calcium carbonate (Tums) 1-2 gm calcium/day. (Tums have 650 mg calcium/tablet) Pulmonary edema Oxygen Furosemide (Lasix) Digitalization is not effective Peripheral edema Furosemide 1-2 mg/kg/dose given bid-tid po or IV Treatment with diuretics decreases the duration and severity of edema and hypertension Acidosis Sodium bicarbonate 1-2 mEq/kg/dose (1-2 mmol/kg/ dose) IV over 30 minutes to correct acidosis Strep infection Give penicillin for 10 days (po if possible) Erythromycin in penicillin allergic patients Hypertension Control with diuretics (furosemide 0.5-1 mg/kg IV or 2 mg/kg po bid or tid) and vasodilators (hydralazine [Apresoline] 0.25-1.0 mg/kg qid or nifedipine 0.25 mg/kg po prn or qid) Contraindications: Refer to manufacturers literature Precautions: Refer to manufacturers literature Significant possible interactions: Refer to manufacturers literature ALTERNATIVE DRUGS N/A FOLLOW-UP PATIENT MONITORING Depends on severity of disease Urinalysis at 2, 4 and 8 weeks and 4, 6 and 12 months Stop follow-up when urinalysis is normal Monitor blood pressure each visit Monitor serum creatinine at 2, 6, and 12 months C3 complement should be normal by 6 weeks PREVENTION/AVOIDANCE Treat streptococcal infections aggressively POSSIBLE COMPLICATIONS Hypertensive retinopathy Hypertensive encephalopathy Rapidly progressive glomerulonephritis Abnormal urinalysis may persist for years (microhematuria) Chronic renal failure (rare) Nephrotic syndrome (approximately 10%) Marked decline in glomerular filtration rate (rare) EXPECTED COURSE/PROGNOSIS Usually self-limited to 2-3 weeks Immediate mortality < 0.5% Long-term: excellent in children; almost all patients recover completely. May have more morbidity in adults or in those with pre-existing renal lesions Microscopic hematuria may persist for 24 months (or longer with complete recovery) Proteinuria persists for up to 3 months Symptoms can be exacerbated by an intercurrent illness but rarely after 12 months

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Urine may be darker (microscopic hematuria) after strenuous exercise MISCELLANEOUS ASSOCIATED CONDITIONS N/A AGE-RELATED FACTORS Pediatric: Common in children ages 2-16 Geriatric: N/A Others: N/A PREGNANCY N/A SYNONYMS Acute nephritic syndrome Postinfectious glomerulonephritis Acute post-streptococcal glomerulonephritis ICD-9-CM 580.9 Acute glomerulonephritis with unspecified pathological lesion in kidney SEE ALSO Glomerulonephritis, membranous Hyperkalemia Renal failure, acute (ARF) Hypocalcemia Hypertensive emergencies OTHER NOTES N/A ABBREVIATIONS N/A REFERENCES Brenner B, Rector F, editors. The Kidney. 6th Ed. Philadelphia: W.B. Saunders Co.; 2000 Barratt T, Avner E, Harmon W, editors. Pediatric Nephrology. 4th ed. Baltimore: Williams & Wilkins; 2000

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