ACUTE

GLOMERULONEPHRITIS
(AGN)
Paediatric Department CME
 Outline

 Definition
 Epidemiology
 Aetiology
 Clinical approach
 Investigation
 Management
Definition

 Acute glomerulonephritis (AGN) is an abrupt

onset of one or more features of an Acute
Nephritic Syndrome
Acute Nephritic Syndrome

 Haematuria
 Oliguria
 Edema
 Azotemia
 Hypertension
Epidemiology

 6-10 years old

 Predominantly male
 Recurrence is rare
Aetiology

1. Post infectious cause (MOST COMMON):

- Streptococcus species (Group A beta haemolytic)

2. Systemic causes
Causes Features
Vasculitis Wegener’s granulomatosis
Collagen vascular diseases SLE
Polyarteritis nodosa Vasculitis involving renal arteries
Henoch Schonlein purpura Generalized vasculitis resulting in
gromerulonephritis
Goodpasture syndrome Circulating antibodies to type 4
collagen (against GBM,
pulmonary BM)
Drug induce Gold, penicillamine
 Aetiology

3. Primary renal disease

i.e IgA nephropathy
- This causes GN as a result of diffuse mesangial deposition of IgA
and IgG.
 Gp A Beta haemolytic streptococcal infection in
pharynx/skin

Formation of immune complex between organism and host

antibodies

Deposition at glomerular filtration membrane

Fix complement (C3)

Inflammation, capillary wall injury, glomerular

damage

Increased capillary wall permeability, loss of plasma

albumin, hemodynamic changes
 Increased capillary wall permeability, loss of plasma
albumin, hemodynamic changes

Edema Reduced GFR RBC escape through

capillary wall

Azotemia Oliguria
Hematuria

Fluid retention
through RAAS

Hypertension
History

1. Signs and symptoms:

 Haematuria
 Oliguria
 Edema (85%)
 Hypertension
 Loin pain

non specific: weakness, fever, abdominal pain, and malaise.

History

2. Risk factors

 Post pharyngitis (1-2 weeks)

 Post dermal infections (2-4 weeks)
- non bullous impetigo ( may have encrusted impetigo)
 Pre-existing renal diseases
History

3. Underlying diseases

Further questions Reason

Sinusitis, pulmonary symptoms,
nephritic syndrome
Joint pain/swelling, abdominal
pain, purpuric rashes
Joint pain, malar rash, oral ulcers
Haemoptysis, nephritic syndrome
Rashes
Wegener’s granulomatosis
Henoch Schonlein Purpura
SLE
Goodpastures syndrome
Vasculitis
History

4. Complications

 Hypertensive crisis (Headache, Blurring of vision, Seizures)

 heart failure/pulmonary edema (Shortness of breath)

Other complications: AKI

Physical examination

 Altered conscious level

 Edema
 Hypertension
 Skin rashes
Investigation

1. Urinalysis

 RBC cast (pathognomonic)

 Haematuria (distorted RBC and fragmented)
 Proteinuria (usually only up to 2+, if > 2+ need to consider nephrotic
syndrome)
Investigation

2. Serological tests

 ASOT ( >200 U)
 Anti-DNAse B (better indication of preceding streptococcal skin
infection)
 Throat/skin swab
Investigation

2. Renal function test

3. Full blood count

 Anaemia (dilutional), leucocytosis
 Investigation

Indications for Renal Biopsy

3. Serum
1.Severe AKIcomplement levels C3, C4
requiring dialysis
2.Features
 C3: low suggesting non-post-infectious AGN as
cause of acute nephritis
 C4: normal
3.Delay in resolution:
- 4.
Oliguria
US KUB>2 weeks
- Azotemia > 3 weeks
- Gross haematuria > 3 weeks
- 5. Renal biopsy
Persistent proteinuria > 6 months
Management
1. Strict monitoring: BP, fluid intake, daily weight gain
with nephritic charting
2. Penicillin V for 10 days : to eliminate beta-hemolytic
streptococcus
3. Fluid restriction 400cc/BSA/day: to control edema &
circulation overload during oliguric phase.
4. Nifedipine: to treat HPT
5. Diet: no added salt
6. Watch out for complications: HPT encephalopathy,
APO, AKI
 Management of hypertension in AGN
Asymptomat
ic
Bed rest and recheck BP ½ hour later

If BP still high, give oral Nifedipine 0.25 - 0.5 mg/kg STAT

Recheck BP ½ hour later, hourly x 4 hours then 4 hourly if

stable

if BP persistently high, for regular oral Nifedipine (6 – 8

hourly)

Add Frusemide 1 mg/kg/dose if BP still not well controlled.

Other options if BP still uncontrolled: Captopril (0.1-0.5 mg/kg q8 hourly) / Metoprolol 1-4 mg/kg 12
hourly
Management of hypertension in AGN
Symptomatic/severe hypertension

Emergency administration of nifedipine

• Target of BP control:
- Reduce BP to <90th percentile of BP for age, gender
and height percentile .
- Total BP to be reduced = Observed mean BP −
Desired mean BP
- Reduce BP by 25% of target BP over 3 – 12 hours.
- The next 75% reduction is achieved over 48 hours.
Management of hypertension in AGN
Pulmonary
edema
Give oxygen

45 degrees, prop up

IV frusemide 2 mg/kg/dose stat

Fluid restriction – withhold fluids for 24 hours if possible.

Close reassessment

If poor response; double the dose 4 hours later

If diuretic not working- DIALYSIS
Follow up

 Follow up for at least 1 YEAR

 Do UFEME AND RP to evaluate recovery
 Monitor BP every visit
 Repeat C3 level 6 weeks later if not already normalized by time
of discharge
Prognosis

 Short term outcome- excellent, mortality < 0.5 %

 Long term outcome- 1.8% with CKD following post
strep AGN
 THE END.
THANK YOU