Acute nephritis

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Acute nephritis

  1. 1. Acute NephritisAcute Nephritis CSN VittalCSN Vittal
  2. 2. DefinitionDefinition • An acute inflammation of renal glomerularAn acute inflammation of renal glomerular paranchyma due to deposition of immuneparanchyma due to deposition of immune complexes characterized by sudden onset ofcomplexes characterized by sudden onset of  oliguria,oliguria,  hematuria,hematuria,  hypertension andhypertension and  edemaedema
  3. 3. IncidenceIncidence • 2 to 4 % of pediatric admissions in India2 to 4 % of pediatric admissions in India • 90 % of renal disease of childhood90 % of renal disease of childhood
  4. 4. EtiologyEtiology • Streptococcal infectionStreptococcal infection • Non streptococcalNon streptococcal • Bacterial : Infective endocarditis, shunt nephritis,Bacterial : Infective endocarditis, shunt nephritis, typhoid, syphilis, S.pneumoniae, meningococcaltyphoid, syphilis, S.pneumoniae, meningococcal • ViralViral : HBV, mumps, varicella, ECHO, coxsackie,: HBV, mumps, varicella, ECHO, coxsackie, measles, infective mononucleosismeasles, infective mononucleosis • AutoimmuneAutoimmune • Goodpastuer’s syndrome, HSP, SLE, IgA nephropathyGoodpastuer’s syndrome, HSP, SLE, IgA nephropathy • MiscellaneousMiscellaneous • GBS, DPT vaccination, Irradiation to Wilms tumorGBS, DPT vaccination, Irradiation to Wilms tumor
  5. 5. PathologyPathology • Gross:Gross: - Both kidneys enlarged- Both kidneys enlarged - Ischemic- Ischemic • Microscopy:Microscopy: - Glomeruli enlarged, infiltrated by polymorphs- Glomeruli enlarged, infiltrated by polymorphs - Epithelial crescents- Epithelial crescents • Immunofluorescence:Immunofluorescence: - Lumpy-bumpy deposits of IgG, antigen and C3- Lumpy-bumpy deposits of IgG, antigen and C3 • Electron microscopy:Electron microscopy: - Mesangial proliferation and mesangial matrix- Mesangial proliferation and mesangial matrix depositiondeposition - Lumps of immune complex depositions seen on- Lumps of immune complex depositions seen on the epithelial side of GBMthe epithelial side of GBM
  6. 6. The Clinical Spectrum of Renal Disease Disease Category (Most to Least Severe) Asymptoma tic (e.g. Thin basement membrane disease) (Least Severe) Chronic progressive glomerulop athy (e.g. Diabetes nephropathy ) Nephrotic syndrome (e.g. Minimal change disease) Nephritic syndrome (e.g. post- infectious GN) RPGN (Most Severe) Clinical Signs / Symptoms Microscopic hematuria Insidious progressive loss of renal function Greater than 3.5 gm of protein in 24 hr urine Hypertensio n, RBC casts, Hematuria, Azotemia Acute renal failure + nephritic syndrom e
  7. 7. AGN - PathophysiologyAGN - Pathophysiology OliguriaOliguria 1.1. Spasm of afferent arteriole (Spasm of afferent arteriole ( blood flow)blood flow) 2.2. Obliteration of lumen by mucosal edema &Obliteration of lumen by mucosal edema & cellular infiltrationcellular infiltration 3.3. Crescents causing obstructionCrescents causing obstruction 4.4.  absorption of Na and water from renalabsorption of Na and water from renal tubulestubules
  8. 8. AGN - PathophysiologyAGN - Pathophysiology HypertensionHypertension 1.1.  absorption of Na and water fromabsorption of Na and water from renal tubulesrenal tubules 2.2.  sympathetic activitysympathetic activity 3.3.  arterial spasmarterial spasm 4.4.  cardiac outputcardiac output
  9. 9. AGN - PathophysiologyAGN - Pathophysiology OedemaOedema 1.1. Retention of Na and water from renalRetention of Na and water from renal tubulestubules 2.2. Circulation of unknown antigen causingCirculation of unknown antigen causing peripheral vasodilatationperipheral vasodilatation
  10. 10. AGN - PathophysiologyAGN - Pathophysiology HematuriaHematuria • Presence of 5 or > RBC per mm3 fresh uncentrifuged midstream urine • >5 RBC per hpf in centrifuged specimen (of 10 ml, at 750 rpm for 5 min) • Macroscopic = > 25000 RBC / ml 1.1. Destruction and denudation of vesselsDestruction and denudation of vessels
  11. 11. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis -- EtiologyEtiology • Streptococcal serotypes involvedStreptococcal serotypes involved • Pharyngitis :Pharyngitis : • Types 1, 3, 4,Types 1, 3, 4, 1212, 25, 49, 25, 49 • PyodermaPyoderma • Types 2,47,Types 2,47, 4949, 55, 57, 60, 55, 57, 60 • Streptococcal antigens involved in immune response :Streptococcal antigens involved in immune response : • Zymogen precursor of exotoxinZymogen precursor of exotoxin • Glutaraldehyde phosphate dehydrogenaseGlutaraldehyde phosphate dehydrogenase Usually occurs 7-14 days after pharyngitis and 2 wks – 6 wks after skin infection
  12. 12. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis Age groupAge group 2 – 12 yrs (Rare before 2 yrs)2 – 12 yrs (Rare before 2 yrs) SexSex Male predominanceMale predominance Socioeconomic groupSocioeconomic group Common in low socioeconomic groupCommon in low socioeconomic group Seasonal variationSeasonal variation During winter and rainy season serotype 12 causesDuring winter and rainy season serotype 12 causes Ac. pharyngitisAc. pharyngitis During summer – serotype 49 causes skin infectionsDuring summer – serotype 49 causes skin infections
  13. 13. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis PathogenesisPathogenesis Type III immunological reaction in whichType III immunological reaction in which glomeruli are damaged due to deposition ofglomeruli are damaged due to deposition of IgG antibodyIgG antibody,, antigenantigen andand complement C3complement C3.. Rarely C1q and C4 may be involvedRarely C1q and C4 may be involved
  14. 14. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis Clinical FeaturesClinical Features • Puffiness of face – more in the morningsPuffiness of face – more in the mornings • Edema feetEdema feet • Oliguria ( < 400 ml / mOliguria ( < 400 ml / m22 )) • Hematuria (cola coloured urine)Hematuria (cola coloured urine) • Breathlessness due to hypertensive heart failureBreathlessness due to hypertensive heart failure • FeverFever • HypertensionHypertension • Abdominal painAbdominal pain • Atypical presentations:Atypical presentations: • Hypertensive encephalopathy – confusion, convulsions, etc.Hypertensive encephalopathy – confusion, convulsions, etc. • Pulomonary edema – due to CHFPulomonary edema – due to CHF • Acute renal failureAcute renal failure
  15. 15. HypertensionHypertension Values AboveValues Above 80 / 4580 / 45 PretermPreterm 90 / 6090 / 60 Term NewbornTerm Newborn 120 / 75120 / 75 Up to 2 yearsUp to 2 years 130 / 80130 / 80 2 – 5 years2 – 5 years 135 / 85135 / 85 6 – 11 years6 – 11 years 140 / 90140 / 90 Older childrenOlder children
  16. 16. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis Diagnostic criteria of APSGNDiagnostic criteria of APSGN At least 2 of the following criteria must be presentAt least 2 of the following criteria must be present 1.1. Positive throat or skin culture forPositive throat or skin culture for streptococcusstreptococcus 2.2. Streptococcal products likeStreptococcal products like antistreptokinase, antihyalironidase, anti-antistreptokinase, antihyalironidase, anti- Dnase B, ASO titre are elevatedDnase B, ASO titre are elevated (Anti –(Anti – DNAse B is the single most specific test forDNAse B is the single most specific test for Stereptococcal infection)Stereptococcal infection) 3. Hypocomplementemia3. Hypocomplementemia C3 and CH50 decreased with in 2 weeksC3 and CH50 decreased with in 2 weeks
  17. 17. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis Investigations - For kidney injury :Investigations - For kidney injury : Urine analysisUrine analysis • Proteinuria – non selectiveProteinuria – non selective • Hematuria :Hematuria : - Macroscopic :- Macroscopic : Plenty of RBC &Plenty of RBC & RBC casts in urineRBC casts in urine - Microscopic :- Microscopic : > 5 RBC / HPF in 10 ml> 5 RBC / HPF in 10 ml centrifuged urinecentrifuged urine • HypocomplementemiaHypocomplementemia Kidney function TestsKidney function Tests • Blood ureaBlood urea • S. creatinine (S. creatinine ( due todue to  GFR)GFR)
  18. 18. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis Investigations - For Etiological FactoresInvestigations - For Etiological Factores 1.1. Culture of organisms in throat or skinCulture of organisms in throat or skin 2.2. Antistreptokinase, antihyalironidase – increasedAntistreptokinase, antihyalironidase – increased 3.3. ASO titer is increased if the disease is due to seroASO titer is increased if the disease is due to sero type 12 (throat infection) but not increased if thetype 12 (throat infection) but not increased if the disease is due to type 49 because subcutaneous lipidsdisease is due to type 49 because subcutaneous lipids prevent the percolation of ASO titer in bloodprevent the percolation of ASO titer in blood 4.4. Single most specific test : Anti DNAse – BSingle most specific test : Anti DNAse – B
  19. 19. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis On light microscopy, usually see diffuse proliferative GN
  20. 20. Immunofluorescence Microscopy Deposition of IgG andDeposition of IgG and C3C3 1. Mesangial 2. Starry sky (mesangial & capillary wall) 3. Garland (capillary loops)
  21. 21. Electron Microscopy • large electron – dense immune deposits in subendothelial, subepithelial, and mesangial areas
  22. 22. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis Course • Renal Failure – less than 1 % in children, slightly higher in adults • Resolution usually quick, • plasma Cr usually returns to previous levels by 3-4 weeks • Hematuria resolves usually within 3-6 months, • Proteinuria falls at a slower rate • Some patients experience htn, recurrent proteinuria, and renal insufficiency 10-40 yrs after • > 20% of adults may have some degree of persistent proteinuria and or compromise of GFR for 1 year
  23. 23. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis ComplicationsComplications 1. Hypertensive encephalopathy1. Hypertensive encephalopathy Failure of autoregulatory system of the vessels ofFailure of autoregulatory system of the vessels of brain due to acute rise of blood pressurebrain due to acute rise of blood pressure • Altered sensorium, convulsions, etc,Altered sensorium, convulsions, etc, 2. Hypertensive heart failure2. Hypertensive heart failure 3. Hypocalcemia3. Hypocalcemia 4. Hyperphosphatemia4. Hyperphosphatemia 5. Hyperkalemia5. Hyperkalemia 6. Acute renal failure6. Acute renal failure
  24. 24. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis Management PrinciplesManagement Principles • Eliminate Strep. infection with antibiotics • Supportive therapy • Diuretics and antihypertensives to control bp and extra-cellular fluid volume
  25. 25. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis ManagementManagement 1. Infections control1. Infections control 2. Treatment of Hypertension2. Treatment of Hypertension 3. Treatment of Edema3. Treatment of Edema 4. Diet4. Diet 5. Fluid5. Fluid 6. Weight monitoring6. Weight monitoring
  26. 26. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis 1. Infections:1. Infections: Drug of choice:Drug of choice: PenicillinePenicilline 4 – 8 Lakhs PPF for 10 days4 – 8 Lakhs PPF for 10 days Management 1. Infections control 2. Treatment of Hypertension 3. Treatment of Edema 4. Diet 5. Fluid 6. Weight monitoring
  27. 27. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis 2. Hypertension:2. Hypertension: Mild cases –Mild cases – managed with salt &managed with salt & water restriction.water restriction. Drugs used : Atenelol,Drugs used : Atenelol, hydralazine,hydralazine, nifedipinenifedipine Management 1. Infections control 2. Treatment of Hypertension 3. Treatment of Edema 4. Diet 5. Fluid 6. Weight monitoring
  28. 28. Management of Hypertensive EncephalopathyManagement of Hypertensive Encephalopathy 1. Intravenous Sodium Nitroprusside1. Intravenous Sodium Nitroprusside [Arterial & venous vasodilator][Arterial & venous vasodilator] Dose : 0.3 µg / kg / min (max 10 µg / kg / min)Dose : 0.3 µg / kg / min (max 10 µg / kg / min) 2. Propranalol2. Propranalol [[ββ 1 selective blocker]1 selective blocker] Dose: 1-3 mg / kg / dose q 12 hDose: 1-3 mg / kg / dose q 12 h 3. Esmolol3. Esmolol [b 1 selective blocker][b 1 selective blocker] Dose: 130 – 300 µg / kg / minDose: 130 – 300 µg / kg / min 4. Nifidepine4. Nifidepine (Calcium channel blocker)(Calcium channel blocker) Dose : 0.5 mg / kg Sublingual repeated after 30 minDose : 0.5 mg / kg Sublingual repeated after 30 min 5. Amlodepine5. Amlodepine (Calcium channel blocker)(Calcium channel blocker) Dose : 0.1 to 0.6 mg / kg / d in 2-3 doses – OralDose : 0.1 to 0.6 mg / kg / d in 2-3 doses – Oral 6.6. LabetelolLabetelol [Combined[Combined ββ -adrenergic (-adrenergic (ββ1 and1 and ββ2) and2) and αα-adrenergic-adrenergic blocker]blocker] Dose : 0.2-1.0 mg/kg can be given as an IV bolus everyDose : 0.2-1.0 mg/kg can be given as an IV bolus every 10 min10 min max bolus dose is 20 mg.max bolus dose is 20 mg. Dosages of 0.25 - 3 mg / kg / hr by IV infusion -Dosages of 0.25 - 3 mg / kg / hr by IV infusion - recommended.recommended. 7.7. HydralazineHydralazine :: [Direct arterial vasodilator with no effect on venous[Direct arterial vasodilator with no effect on venous circulation]circulation]
  29. 29. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis 3. Edema & 5. Fluid3. Edema & 5. Fluid IntakeIntake • Urine out put should be accuratelyUrine out put should be accurately measured.measured. • Fluid intake restricted to anFluid intake restricted to an amount equal to insensible lossesamount equal to insensible losses and 24 hr. urine outputand 24 hr. urine output Diuretics :Diuretics : In presence of pulmonaryIn presence of pulmonary edema:edema: Frusemide 2-3 mg / kg IV Management 1. Infections control 2. Treatment of Hypertension 3. Treatment of Edema 4. Diet 5. Fluid 6. Weight monitoring
  30. 30. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis 3. Edema:3. Edema: • Urine out put should be accuratelyUrine out put should be accurately measured.measured. • Fluid intake restricted to anFluid intake restricted to an amount equal to insensible lossesamount equal to insensible losses and 24 hr. urine outputand 24 hr. urine output Diuretics :Diuretics : In presence of pulmonaryIn presence of pulmonary edema:edema: Frusemide 2-3 mg / kg IV Management 1. Infections control 2. Treatment of Hypertension 3. Treatment of Edema 4. Diet 5. Fluid 6. Weight monitoring
  31. 31. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis 6. Weight monitoring:6. Weight monitoring: • Child should be weighed dailyChild should be weighed daily • In presence of severe oliguria,In presence of severe oliguria, child should lose about 0.5 % ofchild should lose about 0.5 % of body weight per day due tobody weight per day due to endogenous catabolismendogenous catabolism • A gain in weight necessitatesA gain in weight necessitates reduction in fluid intakereduction in fluid intake Management 1. Infections control 2. Treatment of Hypertension 3. Treatment of Edema 4. Diet 5. Fluid 6. Weight monitoring
  32. 32. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis Indications for Renal BiopsyIndications for Renal Biopsy • Severe renal failure requiring dialysisSevere renal failure requiring dialysis • Hypertension – severeHypertension – severe • Unresolving Acute GN :Unresolving Acute GN : - Massive proteinuria persisting > 4 wks- Massive proteinuria persisting > 4 wks - Abnormal renal function (azotemia) - past 2 wks- Abnormal renal function (azotemia) - past 2 wks - Low C3 for more than 8 wks- Low C3 for more than 8 wks - Hypertension or hematuria past 3 wks- Hypertension or hematuria past 3 wks - Urinary sedimentation abnormality persists >18 mo.- Urinary sedimentation abnormality persists >18 mo. • Features of systemic illnessFeatures of systemic illness
  33. 33. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis PreventionPrevention Any streptococcal sore throat or skin infection should beAny streptococcal sore throat or skin infection should be treated withtreated with • Benzyl Penicilline IM single doseBenzyl Penicilline IM single dose 6 Lakh IU - for < 6 yrs age6 Lakh IU - for < 6 yrs age 12 Lakh IU - for > 6 yrs age (or)12 Lakh IU - for > 6 yrs age (or) • Oral Penicilline : 125 mg BID for 10 daysOral Penicilline : 125 mg BID for 10 days • Ampicilline 100 mg / kg / d twice daily for 10 daysAmpicilline 100 mg / kg / d twice daily for 10 days • Amoxicilline 50 mg / kg /d for 19 daysAmoxicilline 50 mg / kg /d for 19 days There is no role for long term prophylaxis in acute nephritisThere is no role for long term prophylaxis in acute nephritis
  34. 34. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis Management of complications:Management of complications: • CCF • Hypertensive encephalopathy • ARF • Uremia • Acidosis • Hyperkalemia • Hyperphosphatemia • Hypocalcemia • Seizures
  35. 35. Post Streptococcal GlomerulonephritisPost Streptococcal Glomerulonephritis PrognosisPrognosis • 95% good prognosis95% good prognosis • Complement returns to normal within 3 wksComplement returns to normal within 3 wks • Microscopic hematuria persists for 1-2 wksMicroscopic hematuria persists for 1-2 wks • Hypertension returns to normal in 2-3 wksHypertension returns to normal in 2-3 wks • 1-5 % Mortality1-5 % Mortality • 1 – 5 % develop into Chronic GN,1 – 5 % develop into Chronic GN, Chronic Renal FailureChronic Renal Failure
  36. 36. ARF (< 1ml / kg / hr) Management Protocol • Fluid & Electrolyte : • Restrict to insensible losses + last day’s output Insensible losses = 400 ml / m2 /day Insensible losses – replaced by 10 % D/W Last day’s out put – 50% by 10% D/W and 50% by N. Saline GI Aspirates - by N. Saline In severely over hydrated child – restrict all fluids Newborn 30 ml / kg /d Infant 25 ml / kg /d 1 – 5 yrs 20 ml / kg /d 5 – 10 yrs 15 ml / kg /d > 10 yrs 10 ml / kg /d
  37. 37. ARF (< 1ml / kg / hr) Management Protocol Hyperkalemia: S. Potassium > 6 mEq / L • 10 % Calcium gluconate – 0.5 ml / kg IV dil . with equal volume of dil. water and cardiac monitoring over 10 minutes. • Soda bicarb 7.5 % = 3 mEq / IV ( 2-3 ml / kg) dil.with equal volume of distilled water or Insulin Glucose solution • Insulin Glucose regimen ( if S.Pot > 7 mEq/L) • 50% glucose 1 ml with plaint insulin 1 unit / 5 G glucose is given over 1 hr
  38. 38. ARF (< 1ml / kg / hr) Management Protocol Acidosis: Corrected slowly and carefully For half correction of bicarbonate value : Bicarbonate (mEq) = 0.3 X weight(kg) X (Desired HCO3 – Observed HCO3 ) Minimum of 15 mEq/L is considered desired serum HCO3
  39. 39. ARF (< 1ml / kg / hr) Management Protocol Hyperphosphatemia: When product of S. phosphorus and S. calcium reaches 70, calcium salts accumulate in urine Restrict phosphorus rich foods ( all protein rich foods) Phosphate binding calcium carbonate antacids – useful
  40. 40. ARF (< 1ml / kg / hr) Management Protocol Hyponatremia: ( S. sodium < 120 mEq / L) Corrected using normal saline Or by Hypertonic 3% Sodium Chloride (1 ml = 0.5 mEq) Na (mEq) = [0.6 X Weight (kg) X (125 - S.Na) ]
  41. 41. Three Types of RPGN Based onThree Types of RPGN Based on Immunofluorescence PatternImmunofluorescence Pattern TypeType PathogenesisPathogenesis Disease(s)Disease(s) PatternPattern StrengthStrength II Anti-GBMAnti-GBM Goodpasture'sGoodpasture's diseasedisease Linear IgG, Weak linearLinear IgG, Weak linear C3C3 greatergreater than 2+than 2+ IIII ImmuneImmune complexcomplex SLE, IgASLE, IgA nephropathynephropathy Granular Ig and C3Granular Ig and C3 capillary loop/mesangiumcapillary loop/mesangium greatergreater than 2+than 2+ IIIIII Pauci-immunePauci-immune or Unknownor Unknown Wegener'sWegener's SyndromeSyndrome Weak/Absent stainingWeak/Absent staining less than 2+less than 2+
  42. 42. Crescentic GN ( RPGN) Focal Segemental Glomerulosclerosis (FSGS)
  43. 43. Clumpy granular deposits IgA nephropathy Goodpasteur syndrome  Lineal deposits
  44. 44. Glomerulonephritides associated with hypocomplimentemia • Poststreptococcal • Other infectious causes • SBE • Shunt nephritis • SLE • Membranoproliferative
  45. 45. Does the treatment of streptococcal skin or pharyngeal infection prevent APSGN? • No study has ever demonstrated that treatment of impetigo or pharyngitis prevents renal complications in the index case. • However, treatment lessens the likelihood of contagious spread to hosts who may be susceptible to renal complications
  46. 46. Some facts about APSGN • Acute rheumatic fever does not occur after the skin infection • About 80-85% of children with APSGN develop elevated ASO titers. • Streptolysin O is bound to lipids in the skin so that the % of individual with streptococcal impetigo who develop +ve ASO titers is much lower. So normal ASO titer does not rule out recent strep. Infection • Streptozyme test will be positive in > 95% of children with documented Strep. infection
  47. 47. Than Q - C.S.N.Vittal- C.S.N.Vittal
  48. 48. All my notes available at : http://snipurl.com/2k691

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