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APSGN.pptx
1.
2.
3.
4. > 5-10 RBC’s/ HPF
from a centrifuged
clean catch
midstream freshly
voided urine sample
Gross (visible to
naked eye) OR
Microscopic
(detected by dipstick
or microscopic exam;
of urine sediment)
≥ 2 consecutive
urine sample
more suggestive.
17. A classical self-limiting
illness resulting from a
prior pharyngeal or
cutaneous infection
with Gp A β-hemolytic
streptococci.
May occur
following
otitis media or
scarlet fever.
18. Pharyngitis Pyoderma
Streptococcal type GP A type 12(4) Type 49 (55)
Climate Temp; or cold Hot, tropical
Season Winter & spring Summer & fall
Age 5-12 yrs Preschool (<5 yrs)
Incubation period 1-2 wks 3 wks
Sex incidence Boys to girl 2:1 Equal in boys & girls.
19. deposited complexes incite glomerular damage by activation of
complement system.
Ag & Ab complexes formed in circulation & deposited in glomeruli.
Immune complex mediated disease.
22. On electron microscopy,
Ag-Ab complexes deposited on epithelial aspect of BM & give
proliferation of outer layers of Bowman’s capsule lead to formation
of epithelial crescents.
Light microscopy,
swelling of endothelial cells of glomerular capillaries,proliferation of
mesangial cells & polymorphonuclear cell infiltration
On gross exam;
kidneys symmetrically swollen & have minute cortical hemorrhages.
Pathologically:
bilateral disease of kidneys affecting all glomeruli.
23.
24.
25.
26. A typical case,
onset;abrupt
Fever,headache,
malaise & vomiting.
passage of red or
cola-colored
urine.
periorbital swelling
esp; in morning but
gross edema unusual.
infection may have passed even unnoticed.
Latent period of 3-6 wks fol; a streptococcal infection of skin
(impetigo) or 1-2 wks following an URTI (pharyngitis)
M:F (3:2) in throat infection
5-12 yrs age, rare < 3 yrs age.
27. Urinary output
↓(< 180 ml/m²/d )
flank or midline abdominal
pain.
Acute hypertension
headache, vomiting, altered sensorium,
visual disturbances,aphasia ,somnolence
or even seizures.
Heart failure or acute renal
failure.
acute phase
lasts 4-10 days, when urine output
gradually ↑ ;edema subsides &
blood urea returns to N.
Gross hematuria
seldom persists beyond 1st wk but
microscopic & casts may persist for
1-2 mons.
Resolution
by 1 mon is rule, although urinary
abnormalities persist for > 1 yr.
31. Clinical course/Natural history
Spontaneous
improvement
• Begins within one
week
Oedema
• Resolves in 5-10 days
Hypertension
• Normalize by 4-6
weeks after onset
Proteinuria
• Normalize by 4-6
weeks
Acute phase
• resolves within 6-8
weeks
Microscopic
hematuria
• may persist for 1-2
years
32. Diagnosis
Clinical diagnosis of APSGN
is likely with
1. Acute nephritic syndrome
2. Evidence of recent
streptococcal infection
• Positive throat culture
• Rising titre to streptococcal
antigen(s)
3. Low C₃ level
Antibodies to streptococcal antigen(s)
• Anti-streptolysin O titre(ASOT) > 333
Todds units
– Commonly elevated after a
pharyngeal infection BUT
– Rarely ↑es after streptococcal skin
infection.
• Anti-deoxyribonuclease(DNase) B
antibodies
– Best single Ab titer to document
cutaneous streptococcal
infection.
• Anti- hyaluronidase antibodies
• Anti- streptokinase antibodies
33. Renal biopsy
• Acute renal failure
• Nephrotic syndrome
• Absence of evidence of
streptococcal infection
• Normal complement
level
• ALSO if
– Hematuria &
proteinuria,↓ renal
function, &/OR low C₃
level persist > 2 months
after onset
38. • Early systemic antibiotic therapy for streptococcal throat & skin
infection does not eliminate the risk of glomerulonephritis
• Family members of patients with acute glomerulonephritis should be
cultured for Gp A β-hemolytic streptococci & treated if culture +ve.
Prevention??
• Can be avoided by appropriate management of:
• Acute renal failure
• Cardiac failure
• Hypertension
Mortality:
39.
40. IgA nephropathy (IgAN)
• Recurrent painless gross hematuria.
• Preceded by (usually 1-3 days) infections
(URTI, AGE).
• Hypertension & renal insufficiency →
uncommon.
• C₃ level → normal
• ASOT or antiDNase B → not elevated
43. Differentiate nephrotic & nephritic syndrome
Features Nephrotic Nephritic
Onset Insidious Abrupt
Edema ++++ ++
BP Normal High
JVP Normal Raised
Proteinuria ++++ ++
Hamaturia ± +++
RBC’s cast Absent Present
Serum Albumin low Normal
44. • Hematuria
• RBC’s casts:
• TLC ±.
• Proteinuria < 200mg/dl.
• Specific gravity > 1.020
• Osmolality > 700 mOsm/kg.
Urine analysis:
• C₃
• Significantly & transiently ↓ in > 90% & return to N in 6-8 wks.
• Must be measured again 6-8 wks after acute episode.
• Failure of C₃ to ↑ to N strongly suggests membrano-proliferative GN, & renal biopsy
indicated.
• CH50
• commonly depressed
• C₄
• Most often normal OR only mildly depressed.
Complement level:
45. • Throat swab
• C/S, 20% asymptomatic carriers of streptococci in nasopharynx.
• Support diagnosis OR represent carrier state
• ↑ ASO titer:
• Common after pharyngitis but rarely after skin infection.
• ↑ 200U/ml suggestive.
• Antideoxiribonuclease (DNase) B level
• Streptozyme test
• More valuable
• measures multiple Ab’s to different streptococcal antigens
Evidence of streptococcal infection:
• Blood urea & creatinine ↑.
Renal function tests:
• Hyponatremia
• hyper-kalemia.
S.electrolytes:
46. • ESR ↑
• Hb ↓ due to hemodilution/low grade hemolysis.
• TLC & DLC N
CBC;
• Indicated in
• Signs of heart failure OR resp distress
• Heart gallop,↓ breath sounds,rales,hypoxemia
• Peri-hilar infiltrates of pulmonary edema.
X-ray chest:
• Indicated in with severe neurological symptoms
• Shows reversible posterior leukoencephalopathy in
parieto-occipital area on T₂-weighted images.
MRI
47. • Rarely indicated,
• considered when
• Acute renal failure,
• nephrotic syndrome,
• Absence of evidence of streptococcal
infection
• Normal complement level
• Hematuria,proteinuria,↓ RFT & persistent
hypo-complementemia for > 2 mon
Renal biopsy:
48. Early & 10-days treatment of streptococcal
infection with penicillin does not eliminate risk
of glomerulonephritis, in contrast to rheumatic
fever. But limit spread of nephritogenic
organisms.
49. • Must be enforced at once in hospital until ESR N.(≈ 4wks).
• Major complications occur within 1st 1-2 wks & carefully watched for.
Bed rest
• Surviving hemolytic streptococci must be eradicated at outset.
• Benzyl penicillin, 5 lac U, IM, BD, or
• PO penicillin-V, 250 mg 4 times/d for 4-5 d.
Antibiotics:
• Fruit juices avoided to limit K⁺ intake to not > 30 meq/d.
• Fluids = 1000-1200 ml/d,half is milk.
• Na =1-2 g esp; if hypertension.
• Calories = 400/m²/d as carbohydrate & fat to prevent tissue catabolism.
Dietary restrictions:
51. Anuria/severe oliguria
• Proteins
• completely withdrawn
• Fluids,
• 10-20% glucose in water = insensible water loss
(400ml/m²/d ) plus urine output.
• To prevent hyperkalemia (≥8mEq/L)
• withdraw K intake completely.
• Correct metabolic acidosis,
• NaHCo₃ also helps in lowering S. K level.
Left ventricular failure;
• Prop up
• Moist O₂
• Restrict Na & fluid intake.
• Digitalize.
• Diuretics,e.g ;frusemide (1-2 mg/kg.d).
• Control BP.
52. Labetalol; 0.2-1.0 mg/kg/dose & then 0.25-2.0 mg/kg/hr infusion
Diazoxide; (hyperstat mg/kg/dose given IV as rapidly as possible . Effects lasts 12-24
hrs
Hydralazine; 0.15 mg/kg/dse IV.
Sublingual nifedipine ;0.25-0.50 mg/kg/dose
Methyldopa; 5-15 mg/kg/dose IV used 20-60 mins
In less urgent situations combination of Hydralazine 0.1-0.5 mg/kg & reserpine 0.05
mg/kg togather IM. Repeated if BP not fall within 2-3 hrs
Hypertension persists Methylopa PO 20-40 mg/kg/d. with concomitant
hypertension 7 circulatory overload . Frusemide 1-2 mg/kg/dose
54. Excellent
Complete recovery, > 95%, occur who survive ac stage
microscopic hematuria may persist for 1-2 yr.
1-2% die during ac stage.
Hypertension resolves within 3 wks.
5% develop hypertensive encephalopathy.
Rarely lead to nephritic syndrome or chronic glomerulonephritis.
