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Agn@rph case management

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  • 1. Case Management: Acute Glomerulonephritis
    • Presentor: Ma. Nieves Elizabeth N. Cruz, MD
    Rizal Provincial Hospital May 25, 2010
  • 2.
    • J.C., 8/f
    • Cardona, Rizal
    • Admitted: April 22, 2010
    • Discharged: April 26, 2010
    GENERAL DATA
  • 3. CHIEF COMPLAINT
    • tea-colored-urine
  • 4. HISTORY OF PRESENT ILLNESS 4 days PTA fever, intermittent; resolved with intake of Paracetamol 3 days PTA tea-colored urine dec.urine output 1 day PTA consult with a PMD RPH
  • 5. PERTINENT P.E. FINDINGS
    • Wt = 28kg
    • Temp = 36°C
    • BP = 100/70 mmHg
    • CR = 100 bpm
    • RR = 23 cpm
  • 6. PERTINENT P.E. FINDINGS
    • No pallor
    • No facial edema
    • + clear breath sounds
    • No respiratory distress
    • No abdominal distension
    • No visible lesions/wounds on extremeties
    • No scrotal/bipedal edema
  • 7. ADMITTING DIAGNOSIS
    • T/C Acute Glomerulonephritis
  • 8. COURSE IN THE WARD
    • 1st HD
    • low salt diet
    • IVF : D5W x kvo
    • Dx’cs :
    • CBC, PC, UA,
    • 24hr-urine-chon,
    • BUN, Crea,
    • ASO, C3,
    • KUB-UTZ
  • 9.
    • 120/90mmHg
    • Tx’cs :
    • Pen G,
    • Paracetamol,
    • Furosemide
    • Nifedipine, 5mg/cap, half cap/SL
    COURSE IN THE WARD
  • 10. COURSE IN THE WARD
    • 2nd HD
    • Yellowish urine
    • IVF: D5 0.3%NaCl
    • Oral fluids limited (accdg.to BSA)
    • BSA (wt)4(9)/100
    • x 100
    • Furosemide IV shifted to p.o.
  • 11. COURSE IN THE WARD
    • 3rd HD
    • u.o. = 0.8cc/24°/kg
    • 4th HD
    • u.o. = 0.9 cc/24°/kg
    • Furosemide ↑ q6°
  • 12. COURSE IN THE WARD
    • 6th HD
    • Discharged
    • Home meds:
    • TMP-SMZ
    • Furosemide x 3days
    • Ascorbic acid
    • Advised repeat KUB-UTZ after 2 weeks
  • 13.
    • Urinalysis:
    • (4/19/10) (4/21/10) (4/25/10)
    • Color : dark yellow, turbid yellow, turbid yellow,sl.turbid
    • pH : acidic acidic acidic
    • sp.gr .: 1.010 1.010 1.010
    • Albumin : +4 +4 trace
    • RBC : loaded plenty 5-7
    • WBC : 5-7 plenty 1-2
    LABORATORY RESULTS
  • 14.
    • CBC
    • (4/19/10)
    • WBC 8.0 seg 0.89
    • lympho 0.30 eos 0.01
    • Hgb 110 hct 0.33
    • Platelet 232
    LABORATORY RESULTS
  • 15.
    • (4/22/10)
    • ASO 400IU/ml
    • C3 28.774 mg/L
    • BUN 6.30
    • Crea 0.70
    • 24°-urine-chon 793.8mg/ 24°
    LABORATORY RESULTS
  • 16.
    • KUB-UTZ:
    • pelvicocaliectasia, rt kidney;
    • left kidney & UB, normal
    LABORATORY RESULTS
  • 17. Acute glomerulonephritis (AGN)
    • is a disease characterized by the sudden appearance of edema, hematuria , proteinuria , and hypertension .
    • It is a representative disease of acute nephritic syndrome in which inflammation of the glomerulus is manifested by proliferation of cellular elements secondary to an immunological mechanism.
  • 18. PATHOPHYSIOLOGY
    • Immune-complex disease
  • 19. A schematic representation of the proposed mechanism for acute poststreptococcal glomerulonephritis (APSGN). C = Activated complement; Pl = Plasmin; NAPlr = Nephritis-associated plasmin receptor; SK = Streptokinase; CIC = Circulating immune complex.
  • 20. Normalization of urine sediment
    • Parameter
    • Gross hematuria
    • Complement level
    • Proteinuria
    • Micro-hematuria
    • Resolved by
    • 2-3 weeks
    • 6-8 weeks
    • 2-6 months
    • 6-12 months
  • 21. TYPICAL COURSE
    • Latent - few days to 3 weeks
    • oliguric – 7 to 10 days
    • diuretic – 7 to 10 days
    • convalescent – 7 to 10 days
  • 22. CLINICAL & LABORATORY PROFILE
    • hematuria (gross) 100%
    • proteinuria 86%
    • edema 85%
    • hypertension 82%
    • hypocomplementenemia 80%
    • cryoglobulinemia 63%
    • gen. malaise, weakness 55%
    • oliguria 52%
    • nausea & vomiting 15%
    • dull, lumbar pain 5%
  • 23. ETIOLOGY
    • 1. Infections
    • Bacterial: GABS, Strep. Viridans, strep. Pneumoniae, S. aureus, S. epidermidis, T. pallidum, Leptospira, S. typhi
    • Viral: hep B, measles, mumps, CMV, enterovirus, GBS, onconavirus
    • Parasitic: toxoplasma, P. malariae, P, falciparum, schistosoma
    • Rickettsial: scrub typhus
    • Fungal: coccidioides immitis
  • 24.
    • 2. Drugs: toxins, antisera, vaccines, DPT
    • 3. Misc: tumor antigen, thyroglobulin, autologous Ig
    ETIOLOGY
  • 25.
    • Group A Beta-hemolytic streptococcus (GABS) Nephritogenic strains
    • Sites:
    • 1. Upper resp. tract: pharyngitis, M1, 2,
    • 4, 12, 18, 25
    • 2. Skin: pyoderma, M49, 55, 57, 60
    • 3. Middle ear : rare
    ETIOLOGY
  • 26. LABORATORY DIAGNOSIS:
      • Urinalysis
    • dec. volume & sp. gravity
    • casts (fine & granular)
    • hematuria (dysmorphic rbc)
    • proteinuria
  • 27.
      • Bacteriology/serology
    • culture of GABS
    • strp antibody titers – ASO (pharyngitis) antiDNAse B (pyoderma), streptozyme
    • serum complement – C3, generally dec. in acute phase, rises during convalescence, normal in 10% of cases
    LABORATORY DIAGNOSIS:
  • 28.
      • Renal function
    • BUN, Crea – usually normal
    • In marked azotemia – metab.acidosis, hyperK, hypoNa, inc. crea
    LABORATORY DIAGNOSIS:
  • 29.
      • Hematology: +dilutional anemia, transient hypoalbuminemia
      • Radiography: CXR – sunburst in congestion, renal utz
    LABORATORY DIAGNOSIS:
  • 30. DIFFERENTIAL DIAGNOSES
    • Low serum complement level
      • Systemic diseases
        • SLE (focal, 75%; diffuse, 90%)
        • Subacute bacterial endocarditis (90%)
        • Visceral abscess
        • "Shunt" nephritis (90%)
        • Cryoglobulinemia (58%)
  • 31.
      • Renal diseases
        • Acute postinfectious glomerulonephritis (>90%)
        • MPGN - Type I (50-80%), type 2 (80-90%)
    DIFFERENTIAL DIAGNOSES
  • 32.
    • Normal serum complement level
      • Systemic diseases
        • Polyarteritis nodosa group
        • Hypersensitivity vasculitis
        • Wegener granulomatosis
        • HSP
        • Goodpasture syndrome
    DIFFERENTIAL DIAGNOSES
  • 33.
      • Renal diseases
        • IgA (or IgG-IgA) nephropathy
        • Idiopathic rapidly progressive glomerulonephritis (RPGN)
        • Anti-glomerular basement membrane (GBM) disease
        • Negative immunofluorescence findings
        • Immune complex disease
    DIFFERENTIAL DIAGNOSES
  • 34. MANAGEMENT
    • Supportive & Symptomatic
    • bed rest, prn
    • fluid & salt restriction
    • Fluids: 400-600 ml/m2/day + UO 24h
    • NaCl ≤ 2g/day
    • K ≤ 40mEq/day
  • 35.
    • Antibiotics:
    • Penicillin 50000-100000 u/kg/d tid-qid x 10days
    • Specific interventions:
    • hypertension
    • CHF
    • Furosemide 2mg/kg/dose/IV
    • Dialysis: if refractory indications: uremia, intractable hyperK, CHF
    MANAGEMENT
  • 36. NORMAL BP VALUES
    • Age
    • NB
    • 8-30days
    • 1 mo – 2 yrs
    • 2-5y
    • 6-11y
    • >12y
    • Upper limit
    • 95 mmHg, systolic
    • 105
    • 115/75
    • 130/80
    • 135/85
    • 140/90
  • 37. PROGNOSIS
    • complete resolution
    • 5-10% progress to chronic state
  • 38. Mortality Rate:
    • 0-7% due to sepsis, CHF, hypertensive enceph
  • 39.
    • Consultation with a pediatric nephrologist is
    • necessary when one or more of the following are
    • present:
    • Severe hypertension
    • Severe oliguria
    • Severe edema
    • Nephrotic-range proteinuria
    • Azotemia (moderate to marked)
    • Recurrent episodes of gross hematuria
    • Persistently depressed C3 (past 8-10 wk)
  • 40. Co nsultation with a pediatric nephrologist is necessary when one or more of the following are present:
    • Atypical onset
      • Absence of latent period
      • No evidence of streptococcal illness
  • 41.
    • Failure of expected resolution of clinical signs
      • Gross hematuria within the preceding 10-14 days
      • Microscopic hematuria within 1 year
      • Edema within 2 weeks
      • Proteinuria (>50 mg/dL) within 6 months
      • Azotemia within 1 week
      • Hypertension within 6 weeks
    Co nsultation with a pediatric nephrologist is necessary when one or more of the following are present:
  • 42. FOLLOW-UP
    • Further Inpatient Care
    • Only a small percentage of patients with acute glomerulonephritis (AGN) require initial hospitalization, and most of those are ready for discharge in 2-4 days.
  • 43.
    • Further Inpatient Care
    • As soon as the blood pressure (BP) is under relatively good control and diuresis has begun, most children can be discharged and monitored as outpatients.
  • 44.
    • Further Outpatient Care
    • Follow up at 0-6 weeks as frequently as necessary to determine the following:
      • Hypertension has been controlled.
      • Edema has started to resolve.
      • Gross hematuria has resolved.
      • Azotemia has resolved.
    • .
    •  
  • 45.
    • Follow up 8-10 weeks after onset to determine the following:
      • Azotemia has subsided.
      • Anemia has been corrected.
      • Hypertension has resolved.
      • C3 and C4 concentrations have returned to normal.
  • 46.
    • Follow up at 3, 6, and 9 months after onset to check the following:
      • Hematuria and proteinuria are subsiding gradually.
      • BP is normal.
  • 47.
    • Follow up at 2, 5, and 10 years after onset to check the following:
      • Urine is normal.
      • BP is normal.
      • Serum creatinine level is normal
  • 48.
    • Follow up at 12 months after onset to determine the following:
      • Proteinuria has disappeared.
      • Microscopic hematuria has disappeared.

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