5. Functions of ME (MR.KIDNEY)
Without me, YOU will UNABLE
to:
Remove wastes and water from the
blood
Balanced chemicals in your body
Release hormones
Help to control blood pressure
Help to produce red blood cells
Produce vitamin D, which keeps
the bones strong and healthy
12. Acute Glomerulonephritis
Acute glomerulonephritis (AGN) is an
abrupt onset of one or more features of an
Acute Nephritic Syndrome :
• Oedema e.g. facial puffiness
• Microscopic / macroscopic haematuria
• Decreased urine output (oliguria)
• Hypertension
• Azotemia
13. Presenting features of AGN
Acute nephritic syndrome (most common)
Nephrotic syndrome
Rapidly progressive glomerulonepritis
Hypertensive encephalopathy
Pulmonary oedema
Subclinical (detected on routine
examination)
14. Causes of Acute Nephritis
Post streptococcal AGN
Post-infectious acute glomerulonephritis (other
than Grp A B-Haemolytic Stretococci)
Subacute bacterial endocarditis
Henoch- Schoelein Purpura
IgA nephropathy
Hereditary nephritis
SLE
Systemic vasculitis
16. In children, the commonest cause of acute
nephritic syndrome is post-infectious
AGN, mainly due to post-streptococcal
infection of the pharynx or skin.
Post streptococcal AGN is commonest at
6-10 years age.
17. Definition
AGN that follows an infection with a
nephritogenic strain of group A beta
hemolytic streptococci.
The classic example of the acute nephritic
syndrome.
Nelson Textbook of Pediatrics, 7th
Edition
19. epiDemiology
Most commonly – sporadic.
Peak incidence - age 2-14 y/o, uncommon <3y/o.
Males are commonly affected than females.
20. etiology anD
pathogenesis
M types of streptococci (nephritogenic strains)
M types 47, 49, 55, 2, 60, and 57 - following impetigo
M types 1, 2, 4, 3, 25, 49, and 12 – pharyngitis
Incubation period:
2–6 weeks after skin infection
1–3 weeks after streptococcal pharyngitis.
21. etiology anD
pathogenesis
Antibodies to streptoccocus (eg antistreptolysin O) are
formed in the circulation
Antigen-antibody circulating immune complexes are
subsequently deposited along the glomerular basement
membrane (GBM).
25. light microscope
not specific for post streptococcal nephritis
•Glomeruli appear enlarged and hypercellular.
•Diffuse mesangial cell proliferation with an increase in mesangial
matrix.
•Polymorphonuclear leukocytes are common in glomeruli during
the early stage of the disease.
26. Deposits localize in the mesangium and along the capillary wall in a
subepithelial pattern and stain dominantly for C3 and to a lesser extent
for IgG
27. typical manifestation
1. Edema
75% of the patients
Face, periorbital area lower extremities generalized
(ascites, pleural effusions)
2. Proteinuria – usually normalize after 4 weeks
3. Oliguria
28. Sign and symptoms
Kidney pain normally happens in the
“flank” region, which is just below the
bottom of rib cage.
29. Sign and symptoms
Cola-colored or diluted, iced-
tea-colored urine from red blood
cells in your urine (hematuria)
Foamy urine due to excess
protein (proteinuria)
30. Sign and symptoms
High blood pressure
(hypertension)
Fluid retention (edema)
with swelling evident in
your face, hands, feet and
abdomen
Fatigue/SOB from
anemia or kidney failure.
Less frequent urination
than usual.
31. Clinical course
Spontaneous improvement typically begins within 1 wk
with resolution of edema in 5-10 days and hypertension
in 2-3 wk, but urinalysis may be abnormal (persistent
microscopic hematuria) for a year.
32. InvestIgatIons
Urinalysis and culture
• Haematuria – present in all patients.
• Proteinuria (trace to 2+, but may be in the
nephrotic range; usually associated with more
severe disease.)
• Red blood cell casts (pathognomonic of acute
glomerulonephritis).
• Other cellular casts.
• Pyuria may also be present.
34. InvestIgatIons
Bacteriological and serological evidence of antecedent
streptococcal infection:
• Raised ASOT ( > 200 IU/ml ).
• Increased anti-DNAse B (if available) – a
better serological marker of preceding
streptococcal skin infection.
• Throat swab or skin swab.
35. InvestIgatIons
Renal function test
• The BUN - elevated in 75% of patients,
• serum creatinine level is increased in one half of the
patients
• Hyperkalemia, hypocalcaemia, hyponatremia, and
metabolic acidosis are seen only in severe patients.
Full blood count
• A mild normochromic anemia may be present from
hemodilution and low-grade hemolysis.
• Leucocytosis may be present.
36. InvestIgatIons
Complement levels
• C3 level – low at onset of symptoms, normalizes by 6wks
• C4 is usually within normal limits in post-streptococcal
AGN.
Ultrasound of the kidneys
• Not necessary if patient has clear cut acute nephritic
syndrome.
37. IndIcatIons for
renal
BIopsy
Severe acute renal failure requiring dialysis.
Features suggesting non post-infectious AGN as the
cause of acute nephritis.
Delayed resolution
• Oliguria > 2 weeks
• Azotaemia > 3 weeks
• Gross haematuria > 3 weeks
• Persistent proteinuria > 6 months
38. dIagnosIs
Acute onset
Symptoms: edema, oliguria, dark urine,
hypertension
Urinalysis: RBCs, protein, casts
Evidences of streptococcal infection:
– Elevated serum titers of Abs to
streptozymes(ASO)
Serum C3 - Reduced
42. ManageMent
Strict monitoring - fluid intake, urine output,
daily weight, BP (Nephrotic chart)
Penicillin V for 10 days (give erythromycin if
penicillin is contraindicated)
Fluid restriction
44. COMPLICATIONS
Look out for complications of post-
streptococcal AGN:
• Hypertensive encephalopathy usually
presenting with seizures
• Pulmonary oedema (acute left ventricular
failure)
• Acute renal failure
47. Prehypertension is defined as a blood pressure
in at least the 90th percentile, but less than the
95th percentile, for age, sex, and height, or a
measurement of 120/80 mm Hg or greater.
Hypertension is defined as blood pressure in
the 95th percentile or greater.
51. fOLLOw-uP
For at least 1 year.
Monitor BP at every visit
Do urinalysis and renal function to
evaluate recovery.
Repeat C3 levels 6 weeks later if not
already normalised by the time of
discharge.
52. OuTCOME
Short term outcome: Excellent, mortality
<0.5%.
Long term outcome: 1.8% of children
develop chronic kidney disease following
post streptococcal AGN.
These children should be referred to the
paediatric nephrologists for further
evaluation and management.
Normal histological structure of a glomerulus. On the right, is a 3-D illustration of a glomerulus.
Left one shows AA = affrent arteriole, EA= Efferent arteriole, BC= Bowman’s capsule, US= Urinary space