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Agn@rph case management

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Agn@rph case management

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

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