2. Case
A 9 yr old presents with h/o of seizures for 1 day.
Mom gives a history that the boy was well until 2
days ago when he started c/o a headache,
swelling of feet and eyes, and passing tea
colored urine. No h/o travel but mom says the boy
had sore throat 2 weeks ago
3. Introduction
Glomerulonephritis, as the term states, is
inflammation of the glomerulus
Acute Glomerular injury with the following
features:
Haematuria (Microscopic or Macroscopic)
Hypertension (due to water and salt retention)
AKI (Oliguria, Uraemia, elevated creatinine)
Oedema (Peripheral or Pulmonary)
The major underlying pathology is inflammation of the
glomerulus
The primary pathology can be in the kidney, or it can
be a consequence of systemic disorders
4. Etiology Causative agent Examples
Post-Infectious
(Immune complex mediated
following infection)
Bacterial
Post-Streptococcal
(80% of cases)
S. aureus, S. pneumoniae, M,
pneumoiae, E. coli, Sypilis, TB
Viral EBV, CMV, HSV, VZV, Hepatitis
B and C, HIV
Parasites Malaria, Schistosomiasis,
Toxoplamosis, Trypanosomiasis
Fungi Candida, Aspergillus,
Cryptococcus, etc
Autoimmune Immune Complex Mediated
Systemic Lupus Erythematosus
Ig A vasculitis (HSP)
IgA Nephropathy
Anti GBM antibodies Anti GBM
Pauciimmune ANCA Vasculitis GPA, MPA
5. Pathophysiology
Depends on the underlying cause
There is a structural disruption of the glomerular basement
membrane
Glomerular filtration barrier (GFB) is formed by a meshwork
of laminin, proteoglycans, and type IV collagen
The GFB allows the filtration of water and small and
medium-sized solutes
The three layers of the glomerular filtration barrier are the
endothelium, glomerular basement membrane (GBM), and
podocytes
7. Pathophysiology
The GFB can be damaged by various
mechanisms
Direct damage to the endothelial cell layer
Deposition of immune complex in subendothelial,
subepithelial, and mesangial space
Disruption of glomerular basement membrane by
primary renal or secondary systemic diseases
Damage to the podocytes' cellular layer
8. Pathophysiology
ofAPSGN
In children, the most common cause of acute
glomerulonephritis is post-streptococcal glomerulonephritis
PSGN appears to be caused by glomerular immune complex
disease induced by specific nephritogenic strains of group A
beta-hemolytic streptococcus (GAS)
The resulting glomerular immune complex disease triggers
complement activation and inflammation
The latent period between GAS infection and PSGN is
dependent upon the site of infection: between one and three
weeks following GAS pharyngitis and between three and six
weeks following GAS skin infection
10. HISTORY
PertinentQuestionstoAsk
Periorbital puffiness in the early morning
Edema in legs in the evening
The change in color, odor, consistency, and output of urine
Recent upper respiratory tract or skin infection
Fever, fatigue
Headache and seizures
Ulcers and rash on the extremities to rule out vasculitis
Hemoptysis and dyspnea may be present in
Goodpasture syndrome (due to cross-reacting antibodies to the alveolar
epithelium)
GPA or MPA (if lungs are affected)
11. SYMPTOMS
The classic symptoms of the nephritic syndrome are:
Periorbital and pedal edema
Hematuria with red or cola-colored urine
Proteinuria in non-nephrotic range (i.e., less than 3.5 gm/day)
and may cause foamy urine when protein content is high
Hypertension or poorly controlled blood pressure (BP) in
patients with previously controlled BP
Seizures due to Hypertension
Renal insufficiency characterized by oliguria (reduced urine
output), and azotemia, due to decreased glomerular filtration
rate (GFR)
12. Physical
Examination
Patient may be Pale
Elevated blood pressure.
The signs of fluid overload may be present
JVP distention
Pitting edema
Crackles on chest auscultation (pulmonary edema)
On cardiovascular examination, a new heart murmur
can be auscultated in patients with infective
endocarditis.
Palpable purpura and painful and swollen joints are
present in patients with systemic diseases like
vasculitis, Henoch-Schönlein purpura, and SLE.
13. Evaluation
Urine analysis is the first step in the evaluation of
nephritic syndrome
Urine can be discoloured by food, medication,
exercise, haemoglobinuria and myoglobinuria
The upper limit of normal excretion of blood in the
urine is 3 RBCs/HPF
In nephritic syndrome
The urine has greater than 5 RBCs/ HPF along with
acanthocytes and dysmorphic RBCs
RBCs casts and in a few cases WBCs casts
Glomerular Hematuria is usually marked with
brownish (cola or tea) coloured urine
15. Investigations
U&Es, Creatinine
Full Blood Count, PBS, ESR, C-reactive Protein
Blood Culture
ASOT, Anti-DNAse B
Urine Culture and Microscopy for casts
UPCR
Throat Swab
C3, C4
ANA, Anti-dsDNA, ANCA, Anti-GBM
KUB Ultrasound
Kidney Biopsy (when indicated)
RF to r/o cryoglobulinemia if suspected
Hepatitis B Surface Antigen and HCV Antibodies
16. Differential
Diagnosis
The following renal diseases have a clinical
presentation similar to the nephritic
syndrome:
Nephrotic syndrome – FSGS, ICGN
Familial nephritis – Alports, Thin Basement
Membrane Disease
Idiopathic hematuria
Anaphylaxis
17. Treatment
The treatment is mainly supportive and consists of:
Fluid and Dietary salt restriction
If fluid overloaded, restrict intake to insensible losses only
The reduced intake of sodium and potassium helps reduce the
retention of water
Bed rest
Antihypertensives
Some patients may come in Hypertensive emergency and this
should be managed with drugs such as Labetalol, Sodium
Nitroprusside and Hydralazine
In those who are not in hypertensive crisis, hypertension can be
treated with ACE inhibitors, ARBs, Amlodipine or Nifedipine
Diuretics: Loop diuretics may be administered to excrete
excess sodium and water retained in the body
Corticosteroids: Help relieve the inflammation in the kidney
and promote healing. This is indicated in patients with RPGN
18. Treatment
Immunomodulators: Immunosuppressive drugs reduce and
block the antigenic effects of the inciting agents especially in
RPGN
Use of corticosteroids and immunomodulators is controversial in
certain causes of the nephritic syndrome, including staphylococcal
endocarditis. It can aggravate the sepsis and result in increased
mortality
Antibiotics: Post streptococcal GN patients with evidence of
streptococcal infection are administered penicillin. Erythromycin
is preferred for patients allergic to penicillin.
Dialysis: In some cases, the disease has a fulminating course
leading to severe AKI requiring renal replacement therapy.
19. Complications
The nephritic syndrome can grossly compromise
renal function and lead to the following
complications.
Acute Kidney Injury and progression to RPGN
Uncontrolled hypertension
Azotemia
Hyperkalemia
Hyperphosphatemia
Hypocalcemia
Heart failure
Hypertensive encephalopathy presenting as seizures and
altered consciousness
20. Prognosis
The prognosis of the nephritic syndrome depends
upon the underlying aetiology, age of the patients
and timely intervention
APSGN is the commonest in children and has
excellent outcome
Adults typically have a chronic fulminating course.
The disease is not resolved in 20 to 74% of the adults
In these patients, the renal function derangement
persists and will result in Chronic Kidney Disease
21. SUMMARY
The nephritic syndrome is a common presentation of most proliferative glomerulonephritides (GN) and
is characterised by haematuria, oliguria, hypertension and edema
The primary pathology can be in the kidney, or it can be a consequence of systemic disorders
Poststrep GN is the commonest cause of Nephritic Syndrome in children and has a good prognosis
Nephritic syndrome may have a variable clinical picture depending on the underlying aetiology
The acanthocytes, dysmorphic red blood cells, and RBC casts are pathognomonic of glomerular
inflammation
The severity of clinical symptoms at the time of presentation determines the prognosis of the disease
Patients with severe oliguria, azotemia, raised creatinine level at the time of presentation have a worse
prognosis.
Supportive treatment should be initiated immediately along with carrying out the evaluation tests for a
specific diagnosis
24. Scenario
5 year old presents with generalized body
swelling is referred to the ER.
His lab tests are as follows:
Urine 4+ proteinuria; Serum albumin 17mmol/l
Cholesterol 12mmol/l; Creatinine 38umol/l; BP 90/60
Questions
Take relevant history
What is the most likely diagnosis
What are the possible aetiologies?
What further investigations would like to do?
25. INTRODUCTION
Nephrotic Syndrome is the commonest
glomerular disease in children
It manifests with oedema, hypoalbuminemia,
heavy proteinuria and hyperlipidaemia.
26. Epidemiology
Incidence 2-7/100000 Children per year - Nandlal
L. et al-2019
Sex predilection Male:Female 2:1
Commonly affects Children between 2- 10 years.
27. Definition:NephroticSyndrome
Nephrotic Range Proteinuria
UPCR ≥ 200 mg/mmol (2 mg/mg) in 1st morning void, or 24hr urine
sample ≥ 1000 mg/m2 per day corresponding to 3 + or 4 + by urine
dipstick
Hypoalbuminemia
Serum Alb <30g/L
OR
Edema
When serum albumin is
not available
28. Classification
Congenital Nephrotic Syndrome
Manifests in the first 3 months of life
Infantile N.S
Manifests after 3 months of life but before 12 months of
life
Primary/Idiopathic NS
Most common and cause is unknown
Secondary NS
Has an identifiable cause
Can present at any age
29. 1. Idiopathic 85% of cases
2. Genetics
3. Infections e.g Syphilis, malaria,toxoplasimosis,schistosomiasis
4.Drugs NSAIDS, Lithium, Mercury, Lead.
5. Autoimmune and connective tissue disorders e.g, SLE, Granulomatosus with
Polyangiitis, Microscopic polyangiitis, IgA nephropathy
6. Malignancies; Lymphoma, leukemia
CAUSES OF CHILDHOOD NEPHROTIC SYNDROME
30. IdiopathicNS
Commonest form of NS
Affecting from 1.15 to 16.9 per 100,000 children per year
globally
85–90% are Steroid Sensitive (SSNS)
70–80% will have at least one relapse during follow-up
50% of these will experience frequent relapses (FRNS) or
become Steroid dependent (SDNS)
10–30% continue to have a relapsing course into young
adulthood
A small percentage will show no response to steroid therapy
of which some will progress to ESKD
32. The podocyte is a polarised epithelial cell with
interdigitating foot processes with a unique cell–cell
junction known as the slit diaphragm
The podocyte, along with the glomerular basement
membrane and the fenestrated glomerular
endothelium, forms a trilayered structure— the
glomerular filtration barrier
The podocyte and filtration barrier allow an
ultrafiltrate almost completely devoid of protein to
pass into the Bowman’s space and proceed onto
the proximal tubule
Normal
33. Podocyte architecture is maintained by an extensive
actin cytoskeleton that enables the glomerular filtration
barrier to withstand the substantial capillary hydrostatic
pressure
Loss of normal podocyte structure, the foot processes
or the slit diaphragm that spans these interdigitations
can lead to loss of albumin in the ultrafiltrate
Podocytes are terminally differentiated cells with
minimal regeneration and thus, vulnerable to injury
Abnormal
36. Pathophysiology
25-Jul-23
Edema:
Under fill theory: hypoalbuminemia
Over fill theory:↑ tubular NaCl reabsorption
secondary to RAAS → intravascular expansion
→ fluid shift following pressure gradient
Hypercholesterolemia
hypoproteinemia → hepatic lipoprotein
synthesis
→ ↑serum lipid (cholesterol, lipoprotein) → lipid
metabolism
37. 25-Jul-23
Sudden onset of dependent pitting oedema
Periorbital
scrotal or vulva
ankle or leg
Weight gain
Ascites
abdominal pain
Diarrhea (due to intestinal oedema)
Respiratory distress (due to pulmonary edema/
pleural effusions or massive ascites)
Decreased urine output
±HTN and Hematuria
Clinical
Manifestation
38. 25-Jul-23
Infection
Spontaneous bacterial peritonitis, cellulitis,
bacteriemia (S.pneumoniae, E.coli)
Steroid and immunosuppressant toxicity
Hypovolaemia
abdominal pain and may feel faint, cold
peripheries, poor pulse volume, hypotension, and
haemoconcentration.
A low urinary sodium (<20mmol/L) and a high
packed cell volume
Complications
39. Thromboembolism
Hypercoagulable state due to decreased
fibrinolytic factors (urinary losses of antithrombin
III, proteins C and S)
Thrombocytosis
exacerbated by steroid therapy
Increased synthesis of clotting factors
Increased blood viscosity from the raised
haematocrit,
This is usually arterial and may affect the brain,
limbs and splanchnic circulation
Hypercholesteroleamia
Acute Kidney Injury (rare)
Complications
41. First time or relapse???
History of oedema noted on awakening in the morning or sudden swelling??
Distribution
Colour changes
Initiating factor? (bee sting)
Painful??
Weight gain (edema)
Respiratory distress (Breathlessness)
Infection, Pleural Effusion/Pulmonary Edema, Ascites
Diarrhea
Urine: frothy
Past medical and drug history: recent illness, allergies, asthma
Nutrition history
Family history
History Taking
42. 25-Jul-23
Assessment of hydration status identifies fluid imbalances (dehydration,
overhydration)
Blood pressure: hypertension
Henoch-Schönlein purpura (purpura)
Systemic lupus erythematosus (e.g. malar rash)
Rales heard on lung auscultation suggest extravascular fluid from overload or
hypoalbuminemia
Palpation and percussion of the abdomen may reveal ascites or masses
Liver enlargement is present in several multisystem diseases (systemic lupus
erythematosus, infections, polycystic disease) and in glomerulosclerosis
Physical
Examination
Physical Examination
48. InitialEpisode
High protein diet
Salt moderation
Treatment of infections
If significant edema – diuretics can be used but cautiously
Mainstay of therapy is Corticosteroid treatment with Prednisolone
First episode:
Prednisone 2mg/kg(60mg/m2) daily for 6weeks then taper
Second episode:
Prednisone 2mg/kg(60mg/m2) until protein free for 3 days then taper
Prevention:
Prednisone 1mg/kg daily x 5 days when URTI/Vaccines
Initial Episode
49. Treatment Related Definitions
• Complete remission
o UPCR (based on first morning void or 24 h urine sample) ≤ 20 mg/mmol (0.2
mg/mg) or < 100 mg/m2 per day, respectively, or negative or trace dipstick on
three or more consecutive days
• Steroid-sensitive nephrotic syndrome (SSNS)
o Complete remission within 4 weeks of PDN at standard dose (60 mg/m2/day or
2 mg/kg/day, maximum 60 mg/day)
• Steroid-resistant nephrotic syndrome (SRNS)
o Lack of complete remission within 4 weeks of treatment with PDN at standard
dose
• SSNS late responder
o A patient achieving complete remission during the confirmation period (i.e.
between 4 and 6 weeks of PDN therapy) for new onset NS
50. Treatment Related Definitions
• Infrequently relapsing Nephrotic Syndrome
o < 2 relapses in the 6 months following remission of the initial episode or <3
relapses in any subsequent 12-month period (modified definition)
• Frequently relapsing Nephrotic Syndrome (FRNS)
o ≥ 2 relapses in the first 6-months following remission of the initial episode or ≥
3 relapses in any 12 months (modified definition)
• Steroid-dependent nephrotic syndrome (SDNS)
o A patient with SSNS who experiences 2 consecutive relapses during
recommended Prednisolone therapy for first presentation or relapse or within
14 days of its discontinuation
51. Definition: Relapse
• Relapse
o Urine dipstick ≥3+ or UPCR ≥ 200 mg/mmol (≥ 2 mg/mg) on a spot urine sample
on 3 consecutive days, with or without reappearance of edema in a child who
had previously achieved complete remission
• Complicated Relapse (New Definition)
o A relapse requiring hospitalization due to one or more of the following: severe
edema, symptomatic hypovolemia or AKI requiring IV albumin infusions,
thrombosis, or severe infections (e.g., sepsis, peritonitis, pneumonia, cellulitis)
52. Treatment-Related Definitions: SSNS
• Steroid toxicity
o New or worsening obesity/overweight
o Sustained hypertension
o Hyperglycemia
o Behavioral/psychiatric disorders, sleep disruption
o Impaired statural growth (height velocity < 25th percentile and/or height
< 3rd percentile) in a child with normal growth before start of steroid
treatment
o Cushingoid features, striae rubrae/distensae,
o Glaucoma, ocular cataract
o Bone pain, avascular necrosis
53. Mx of oedematous state
Bed rest to be avoided as there is a tendency of hypercoagulability
Dietary advice: no added salt, normal protein with adequate calories
Prophylactic antibiotics: oral penicillin particularly in during relapse with
gross oedema
Hypovolaemia: infuse salt poor albumin or 5% albumin, plasma protein
derivatives or human plasma.
• Note that the patient should be passing urine as you risk causing pulmonary oedema
• Diuretics: to be given cautiously
MANAGEMENT
55. Steroidtoxicity
• Stunting of growth
• Cataracts
• Striae
• Severe cushingoid features
• behavioural changes, a rounded face, central obesity
and the tendency to bruise more easily, hirsutism
• Osteoporosis
• Proximal myopathy
• Recurrent infection due low immunity
58. Managementof
Complications
Infection: parenteral penicillin and a third
generation cephalosporin (in primary
peritonitis)
If exposed to chickenpox and measles
varicella-zoster immunoglobulin (VZIG) should
be given within 72 hours after exposure to
chickenpox / single dose of intravenous
immunoglobulin
Thrombosis : Warfarin, low-dose aspirin, and
dipyridamole all have been used to minimize
the risk of clots.
25-Jul-23
59. EDUCATION
Parents and school teachers should be
provided with information regarding the disease
which includes:
1. Advice and precaution of infection
2. Danger of sudden steroid withdrawal (adrenal
crisis)
3. Immunization:
While the child is on corticosteroid treatment and
within 6 weeks after its cessation, only killed
vaccines may be safely administered to the child.
Live vaccines can be administered 6 weeks after
cessation of corticosteroid therapy
In immune complex–mediated diseases
Antibody is produced against and combines with a circulating antigen that is usually unrelated to the kidney
The immune complexes accumulate in GBMs and activate the complement system, leading to immune injury
anti-GBM antibody disease
Auto- antibodies are formed against Type IV collagen in the basement membrane
Nephritogenic antigens
There are two leading candidates for the putative streptococcal antigen(s) responsible for PSGN
Nephritis-associated plasmin receptor (NAPlr), a glycolytic enzyme, which has glyceraldehyde-3-phosphate dehydrogenase (GAPDH) activity. NAPlr has a plasmin-like activity which may promote a local inflammatory reaction.
Streptococcal pyrogenic exotoxin B (SPE B), a cationic cysteine proteinase, has been localized in the subepithelial deposit
angiotensin-converting enzyme (ACE) inhibitors should be used with caution due to the risk of hyperkalemia
Rationale: Change in definitions was necessitated by the need to reduce exposure to Prednisolone