Acute Glomerulonephritis

ACUTE GLOMEURLONEPHRITIS
Q&A COUNT: 34*

Relevant Findings to this case:
History:
1) C/C: Decreased urine output and Hematuria for ___ days
2) No H/O Facial puffiness (to rule out Nephrotic syndrome)
3) Decreased urine output - Number of times/day, with hematuria*
4) H/O sore throat 1-3 weeks back, treatment taken or not?
(or)
5) H/O skin infections around 1 month back (treated or not)
6) H/O seizures or blurred vision or headache (for hypertensive encephalopathy due to Glomerulonephritis)
7) No H/O orthopnea, dyspnea, PND (in case of complication in Nephrotic syndrome - CCF)
8) No H/O recurrent respiratory tract infections (complication in Nephrotic syndrome)
9) No H/O abdominal pain or distension (as in Nephrotic syndrome)
10) Socio-environmental history: Overcrowding*

Examination:
No edema or anasarca
BP can be elevated*, otherwise normal
No renal angle tenderness

HISTORY

SORE THROAT

Q: Time interval between sore throat and hematuria in Post streptococcal glomerulo nephritis

ANS: 1-3 weeks

Q: What are the reasons if this time interval is less than 1-3 weeks?

ANSWER:

Prior past infection

Fulminant Nephritis (not comfortable, edematous child with uncontrolled BP)

IRGN - Infection Related Glomerulo Nephritis (Nephritis and Infection can occur the same time in IRGN; IRGN can affect both children and adults)
IgA nephropathy** (it takes 1-4 days* from onset of pharyngitis to hematuria)

Q: What is IRGN? What are the organisms causing IRGN?

IRGN - Infection Related Glomerulo Nephritis (Nephritis and Infection can occur the same time in IRGN; IRGN can affect both children and adults)
Streptococcus and Staphylococcus are the causative agents.

Q: Time interval between streptococcal skin infection and hematuria is 6 weeks (more than sore throat's 1-2 weeks). Why?

Answer:

Expression of antigens is late in a skin infection, compared to sore throat

Q: Other organisms (than group A beta hemolytic streptococcus) which can cause Post infectious Glomerulonephritis

Staphylococci
Pneumococci
Meningococci
Salmonella
Leptospira
Trepanoma Pallidium

Q: Why not all child which gets streptococcal sore throat develops AGN?

Answer:

Specific genetic HLA antigens should be there as a pre-disposing factor to get sensitized to the ANTIGEN

Q: Strain types of Group A Beta hemolytic streptococci which causes PSGN?
Strain types 1,4,12

HEMATURIA

Q1: Causes of Hematuria

The above picture is taken from OP Ghai Textbook of Paediatrics

Q2: What are called as the Impostors of Hematuria?

Rifampicin

Beetroot (red urine)

Dyes (Phenothiazine)
These cause false impression of a hematuria

Q3: What are the different colors of Hematuria?

COLA COLOUR - denotes upper Urinary tract involvement

RED (frank hematuria) - denotes lower Urinary tract involvement

Q4: What is Upper Urinary Tract and Lower Urinary Tract?

Upper Tract - Kidney upto Renal pelvis

Lower Tract - Ureter, Bladder, Urethra

Q5: How to differentiate Upper and Lower urinary tract involvement ?

Upper tract involvement produces microscopic urine CASTS, Proteinuria and distorted/ dysmorphic RBC in urine

(These changes indicate glomerular involvement)

Q6: How to differentiate Glomerular and Non Glomerular causes of hematuria

The above picture is taken from OP Ghai Textbook of Paediatrics

Q7: Causes of Recurrent Hematuria

1. IgA nephropathy
2. Alports syndrome
3. Thin glomerular Basement membrane disease
4. Hypercalciuria
5. Urolithiasis

EDEMA

Q1: Mechanisms of edema in Nephrotic syndrome and AGN

Nephrotic syndrome: Decreased osmotic pressure

AGN: Increased hydrostatic pressure

(Note that both disease follow different mechanisms to produce same edema)

Q2: How to differentiate Cardiac and Renal edema?

Cardiac edema occurs in Dependent parts like Pre-sacral edema (dependent part on sitting)

Q3: How to check Pre-sacral edema?

Same as how you check Pedal edema.
Done in sacral and coccyx regions**

Q4: Till when, you can check pre-sacral edema?

Answer:

Till the child starts to walk (it will sit to make its pre sacral area as its dependent part)

Q5: Why facial puffiness is particularly seen in Renal disease edema, why not other edema's?

Cause is unknown**

OTHERS

Q1: Causes of Joint pain + Nephritis

Rheumatic fever

Septic arthritis

Gout (not common)

Henoch Schonlein purpura

Q2: History of similar episodes in past - Inference

The case will not be Post Streptococcal Glomerulo nephritis (since recurrence is very rare, PSGN is ruled out)

Q3: Environmental history related to this case

Answer:

OVERCROWDING

EXAMINATION

Q1: Renal angle tenderness - Causes:

Answer:

Pyelonephritis

Pyonephrosis

Hydronephrosis

Any mass

Q2: Boundaries of Renal angle

Located between the lateral border of erector spinae muscle and inferior border of the twelfth rib

DISCUSSION:

Q1: Name the nephritogenic strains of streptococcus which causes skin infection and sore throat
Type 4, 12 - sore throat
Type 49 - Skin infection

Q2: Most common cause of Glomerulonephritis

Answer: Post streptococcal GN

Q3: Causes of Glomerulonephritis

The above picture is taken from OP Ghai Textbook of Paediatrics

Q4: Secondary causes of AGN

Answer:

IgA nephropathy

Alport syndrome

Nephritis in Nephrotic syndrome

Q5: Inherited causes of Renal failure

Answer:

Polycystic kidney disease

IgA nephropathy

Lupus nephritis

Thick GBM disease

Alport syndrome

Q6: Most common cause of vasculitis in Paediatrics

Henoch Schonlein purpura

Q7: Headache in a case of Renal disease - Possible reasons:

Complications of AGN:

Pulmonary congestion

Hypertensive encephalopathy

Q8: DIFFERENTIAL DIAGNOSIS in a case of AGN

Urinary Tract infection
IgA nephropathy
Alport syndrome
Acute exacerbation of chronic glomerulo nephritis

Q9: TREATMENT modality in Nephrotic syndrome and AGN

For AGN:
1. Dietary sodium, Potassium and fluid restriction
2. Daily urine output and weight chart
3. Diuretics (Furosemide) 1-3 mg/kg
4. Antihypertensives (Amlodipine or diuretics)
5. Penicillin in case of "active" sore throat or skin infections

For atypical presentations of AGN:
4. LVF - IV furosemide
5. Acute renal failure - Dialysis
6. Hypertensive encephalopathy - IV nitroprusside or labetalol (anticonvulsants in case of seizures)
7. Pulmonary edema - IV Furosemide at higher dose (2-4 mg/kg)

For Nephrotic syndrome:
1. High protein diet
2. Normal salt intake - no extra salt should be given
3. Screen for TB*
4. Diuretics for edema (Furosemide 1-4 mg/kg/day in 2 divided doses)
5. Steroids or Steroid sparing agent (Cyclosporine, Tacrolimus or MMF or Cyclophosphamide) (based on whether the disease steroid sensitive or steroid resistant)

Q10: Differences between Nephrotic syndrome and AGN

The above picture is taken from Aruchamy Textbook of Paediatrics

*******

Annexure:
HISTORY:

1) Demography - Name, Age, Gender, Area, Order of Birth, Consanguinity, Informant and reliability

2) Chief complaints - Decreased Urine output and blood in urine for past "x" days

3) History of presenting illness:

Ask H/O of hematuria
H/O sore throat or skin infection + interval between sore throat/skin infection and hematuria
H/O LRI or ADD - usually triggers antibodies for IgA nephropathy* (synpharyngitic hematuria)
Ask H/O facial puffiness - to rule out Nephrotic syndrome
Ask H/O seizures, blurred vision, headache - for Hypertension

Ask H/O of heart failure symptoms (dyspnoea, orthopnoea, PND) - complication of Nephrotic syndrome

4) Past History - H/O similar episodes in past along with any treatment given

5) Antenatal History - all 3 trimesters (no significant role in this case)

6) Birth History (no significant role in this case)

7) Postnatal History (breastfeeding/weaning) (no significant role in this case)

8) Developmental History - all 4 milestones (Milestones attained appropriate for age, Developmental quotient = 100%)

9) Diet History (no significant role in this case)

10) Family History - Not significant usually

11) Socio-environmental History (Socio economic class & Environmental history) (Overcrowding is a factor involved in post streptococcal glomerulonephritis)

12) Immunization History (no significant role in this case)

13) Contact History (no significant role in this case)

14) Allergy History (no significant role in this case)

EXAMINATION:

1) General examination - Normal, look for signs of cardiac failure if any

2) Vitals - Normal (BP can be high)

3) Anthropometry - Normal

4) Head to Toe examination - Normal, look for signs of cardiac failure if any

5) Systemic examination - all 4 systems

Normal (when kept in exams)
CNS - focal neuro deficits (in case of encephalopathy) (will not be kept for exams)
RS - Crepts heard (Pulmonary edema)
CVS - Basal crepts heard (LVF)

DIAGNOSIS
1. A case of Acute post-streptococcal glomerulonephritis with:
2. Normal Immunization status (or) not immunized upto date,
3. Normal Anthropometry (or) mention abnormal anthropometric measure,
4. Protein deficit in %, Calorie deficit in % (or) No protein or calorie deficit,
5. Normal Developmental status (or) Developmental delay with DQ of ___%,
6. (And Mention if any) poor socio-environmental conditions like _____

INVESTIGATIONS

Basic investigations:
1) Three consecutive early morning samples - 3+ or 4+ proteinuria
2) 24 hour urinary protein >50 mg/kg/day
3) Spot Urine protein: Creatinine ratio (>3 in Nephrotic syndrome)
4) Serum protein (Total <5 g/dl or Albumin <2.5 g/dl)
5) Lipid profile
6) Complete hemogram
7) Renal function test
8) USG Abdomen and Xray KUB region
9) Urine Microscopy
10) Throat swab - culture and sensitivity (if infection persists)

Specific investigations:
1. ASO titre
2. Serum C3, C4 levels
3. Serum electrophoresis
4. ANA
5. HbsAg
6. Echocardiogram - for LVF

TREATMENT