Acute glomerulonephritis

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Acute
glomerulonephritis

• By Deepa

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• Definition
• Characterized by acute onset of
• edema
• hematuria
• oliguria
• hypertension
• Impairment of renal function
• facial edema

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• Causes
• A) Post infectious
• Bacterial Group A ß hemolytic streptococci
• staphylococcus , Pneumococcus ,
• Salmonella
• Viral Hepatitis B C , Mononucleosis
• B) GN of undetermined etiology
• Membranoproliferative GN
• Rapidly progressive GN

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• C) Collagen vascular diseases
• SLE
• Henoch Schonlein Syndrome
• Polyarteritis Nodosa
• D) IgA nephropathy
• E) Familial Nephropathy Alport Syndrome
• AGN following Streptococcal infection is the most
  common type in children

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Post streptococcal GN

• Follows infection of throat or skin with
• Group A ß hemolytic streptococci (usually 1 4
  weeks)
• Common strains 12 , 4 , 1 with Pharyngitis
• Type 49 with Pyoderma
• Mainly involves school age boys
• IS an Immune Complex Disease.

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• The antibody formed against streptococcus
  combines with antigen and forms Immune complex
• Immune complex deposition along the capillary
  wall
• Active complement
• Inflammatory changes
• Glomerular injury

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• Pathology
• on light microscopy
• Glomeruli are enlarged , hypercellular ,
  ischemic capillary loops narrowed
• Hypercellularity due to
• Infiltration by leucocytes , both neutrophils
  monocytes
• Proliferation of endothelial mesangial cells
• In severe cases by crescent formation
• Swelling of endothelial cells along with
  proliferation leucocytic infiltration
  obliterates the capillary lumen
• There may be interstitial edema inflamation.
  Tubules often contain red cell casts

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• Immunofluorescence staining
• Granular deposits of IgG , IgM , C3 along the
  capillary walls basement membrane
• Electron Microscopy
• Discrete, amorphous, electron dense deposits on
  the subepithelial side of capillary basement
  membrane often shows Lumpy deposits.

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• Clinical features
• Rapid onset with puffiness around the eyes
  pedal edema
• hematuria
• hypertension
• varying degree of oliguria
• urine is smoky, cola-coloured
• pleural effusion ascites uncommon
• Atypical presentation
• convulsions due to hypertensive encephaclopathy
• left ventricular failure pulmonary edema
• Acute renal failure

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• Laboratory findings
• Urine examination
• shows red blood cells (dysmorphic) and granular
  casts.
• significant protienuria (1 to 2)
• white cells indicative of glomerular
  inflammation
• Hemodilution Normocytic normochromic anemia
  
• ESR
• Blood levels of urea creatinine elevated during
  early phase (return to normal within 2-3 weeks)
• With continuing oliguria hyponatremia
  hyperkalemia

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• Chest X-ray
• prominent vascular markings suggesting
  hypervolemia
• mild cardiomegaly
• pleural effusion
• ASO titre
• Anti hyaluronidase , anti deoxyribonuclease ,
  anti NADase (decrease in 4 to 6 weeks)
• Total hemolytic complement (CM 50) C3 are
  reduced (returns to normal in 8 weeks)

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• A renal biopsy is indicated only in patients
  where clinical features are atypical
• age of onset lt 2 yrs
• pressure of systemic features including
  arthritis, skin rash, hepatosplenomegaly
• absence of elevated ASO titre normal C3 levels
• prior h/o renal disease
• oliguria azotemia rapidly worsen or do not
  resolve with 2-3 weeks

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• Treatment
• Mainly supportive
• Diet
• intake of protein (0.6 g/kg/body.wt/day) sodium,
  potasium should be restricted till blood urea
  urine output
• fluid intake should be restricted to an amount
  equal to insensible losses 24 hr urine output
• Weight
• should be weighed daily
• in severe oliguria should lose 0.5 body wt./day
  because of endogenous catabolism
• oral or parentral penicillin if throat or skin
  culture reveal Group A streptococcus

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• Diuretics
• if pulmonary edema iv frusemide 2-4 mg/kg
• not indicated, since edema is rarely massive and
  gradually disappears with return of renal
  function
• Control of BP is essential
• Mild hypertension- restrict salt water intake
• Atenolol, hydralazine or nifedipine are
  effective
• malignant HT- iv Nitroprusside/ Labetalol

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• Prolonged oliguria
• level of blood urea elctrolytes monitered
• dialysis is required in children with
• renal failure
• prolonged oligoanuria
• fluid overload
• life threatening electrolyte disturbance
• Left ventricular failure
• HT controlled iv frusemid given
• if immediate diuresis not seen step to
  initiate urgent dialysis
• venesection with removal of 100-200 mi of blood
  or trying rotating torniquets to reduce
  venous return to the heart
• respiratory support with positive end-expiratory
  pressure may be needed

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• Prognosis
• Good prognosis in children
• Loss of edema fall in BP in first week
• Gross hematuria significant proteinuria
  disappears in two weeks.
• Microscopic hematuria slight proteinuria may
  be present

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Thank you.........