Case Management: Acute Glomerulonephritis Presentor: Ma. Nieves Elizabeth N. Cruz, MD Rizal Provincial Hospital Rizal Provincial Hospital May 25, 2010 May 25, 2010 1
Case Management:Acute Glomerulonephritis
Presentor: Ma. Nieves Elizabeth N. Cruz, MD
Rizal Provincial HospitalRizal Provincial HospitalMay 25, 2010May 25, 2010
1
• J.C., 8/f• Cardona, Rizal
• Admitted: April 22, 2010• Discharged: April 26, 2010
GENERAL DATA
2
CHIEF COMPLAINT
tea-colored-urine
3
HISTORY OF PRESENT ILLNESS
4 days PTA fever, intermittent; resolved with intake of Paracetamol
3 days PTA tea-colored urine dec.urine output
1 day PTA consult with a PMD
RPH
4
PERTINENT P.E. FINDINGS
• Wt = 28kg• Temp = 36°C• BP = 100/70 mmHg• CR = 100 bpm• RR = 23 cpm
5
PERTINENT P.E. FINDINGS
•No pallor•No facial edema•+ clear breath sounds•No respiratory distress•No abdominal distension•No visible lesions/wounds on extremeties
•No scrotal/bipedal edema
6
ADMITTING DIAGNOSIS
T/C Acute Glomerulonephritis
7
COURSE IN THE WARD
1st HD low salt dietIVF: D5W x kvoDx’cs: CBC, PC, UA, 24hr-urine-chon, BUN, Crea, ASO, C3, KUB-UTZ
8
120/90mmHg
Tx’cs: Pen G, Paracetamol,Furosemide
Nifedipine, 5mg/cap, half cap/SL
COURSE IN THE WARD
9
COURSE IN THE WARD
2nd HD
Yellowish urine
IVF: D5 0.3%NaClOral fluids limited
(accdg.to BSA)
BSA (wt)4(9)/100 x 100
Furosemide IV shifted to p.o.
10
COURSE IN THE WARD
3rd HDu.o. = 0.8cc/24°/kg
4th HDu.o. = 0.9 cc/24°/kg
Furosemide ↑ q6°
11
COURSE IN THE WARD
6th HD DischargedHome meds: TMP-SMZ Furosemide x 3daysAscorbic acid
Advised repeat KUB-UTZ after 2 weeks
12
Urinalysis:
(4/19/10) (4/21/10) (4/25/10)
Color: dark yellow, turbid yellow, turbid yellow,sl.turbidpH: acidic acidic acidicsp.gr.: 1.010 1.010 1.010Albumin: +4 +4 traceRBC: loaded plenty 5-7WBC: 5-7 plenty 1-2
LABORATORY RESULTS
13
CBC (4/19/10) WBC 8.0 seg 0.89 lympho 0.30 eos 0.01
Hgb 110 hct 0.33 Platelet 232
LABORATORY RESULTS
14
(4/22/10) ASO 400IU/ml
C3 28.774 mg/L BUN 6.30
Crea 0.70 24°-urine-chon 793.8mg/ 24°
LABORATORY RESULTS
15
KUB-UTZ:
pelvicocaliectasia, rt kidney; left kidney & UB, normal
LABORATORY RESULTS
16
Acute glomerulonephritis (AGN)
is a disease characterized by the sudden appearance of edema, hematuria, proteinuria, and hypertension.
It is a representative disease of acute nephritic syndrome in which inflammation of the glomerulus is manifested by proliferation of cellular elements secondary to an immunological mechanism.
17
PATHOPHYSIOLOGY
Immune-complex disease
18
A schematic representation of the proposed mechanism for acute poststreptococcal glomerulonephritis (APSGN). C = Activated complement;
Pl = Plasmin; NAPlr = Nephritis-associated plasmin receptor; SK = Streptokinase; CIC = Circulating immune complex.
19
Normalization of urine sediment
Parameter
• Gross hematuria• Complement level• Proteinuria• Micro-hematuria
Resolved by
• 2-3 weeks• 6-8 weeks• 2-6 months• 6-12 months
20
TYPICAL COURSE
• Latent - few days to 3 weeks• oliguric – 7 to 10 days• diuretic – 7 to 10 days• convalescent – 7 to 10 days
21
CLINICAL & LABORATORY PROFILE
• hematuria (gross) 100%• proteinuria 86%• edema 85%• hypertension 82%• hypocomplementenemia 80%• cryoglobulinemia 63%• gen. malaise, weakness 55%• oliguria 52%• nausea & vomiting 15%• dull, lumbar pain 5%
22
ETIOLOGY
1. InfectionsBacterial: GABS, Strep. Viridans, strep.
Pneumoniae, S. aureus, S. epidermidis, T. pallidum, Leptospira, S. typhi
Viral: hep B, measles, mumps, CMV, enterovirus, GBS, onconavirus
Parasitic: toxoplasma, P. malariae, P, falciparum, schistosoma
Rickettsial: scrub typhusFungal: coccidioides immitis
23
2. Drugs: toxins, antisera, vaccines, DPT
3. Misc: tumor antigen, thyroglobulin, autologous Ig
ETIOLOGY
24
Group A Beta-hemolytic streptococcus (GABS) Nephritogenic strains
Sites: 1. Upper resp. tract: pharyngitis, M1, 2, 4, 12, 18, 252. Skin: pyoderma, M49, 55, 57, 603. Middle ear : rare
ETIOLOGY
25
LABORATORY DIAGNOSIS:
Urinalysis
• dec. volume & sp. gravity• casts (fine & granular)• hematuria (dysmorphic rbc)• proteinuria
26
Bacteriology/serology• culture of GABS• strp antibody titers – ASO
(pharyngitis) antiDNAse B (pyoderma), streptozyme
• serum complement – C3, generally dec. in acute phase, rises during convalescence, normal in 10% of cases
LABORATORY DIAGNOSIS:
27
Renal function
• BUN, Crea – usually normal• In marked azotemia – metab.acidosis,
hyperK, hypoNa, inc. crea
LABORATORY DIAGNOSIS:
28
• Hematology: +dilutional anemia, transient hypoalbuminemia
• Radiography: CXR – sunburst in congestion, renal utz
LABORATORY DIAGNOSIS:
29
DIFFERENTIAL DIAGNOSES
• Low serum complement level• Systemic diseases• SLE (focal, 75%; diffuse, 90%)• Subacute bacterial endocarditis (90%)• Visceral abscess• "Shunt" nephritis (90%)• Cryoglobulinemia (58%)
30
• Renal diseases
• Acute postinfectious glomerulonephritis (>90%)
• MPGN - Type I (50-80%), type 2 (80-90%)
31
DIFFERENTIAL DIAGNOSES
• Normal serum complement level• Systemic diseases• Polyarteritis nodosa group• Hypersensitivity vasculitis• Wegener granulomatosis• HSP• Goodpasture syndrome
32
DIFFERENTIAL DIAGNOSES
• Renal diseases• IgA (or IgG-IgA) nephropathy• Idiopathic rapidly progressive
glomerulonephritis (RPGN)• Anti-glomerular basement membrane
(GBM) disease• Negative immunofluorescence findings• Immune complex disease
33
DIFFERENTIAL DIAGNOSES
MANAGEMENT
Supportive & Symptomatic• bed rest, prn• fluid & salt restriction• Fluids: 400-600 ml/m2/day + UO 24h• NaCl ≤ 2g/day• K ≤ 40mEq/day
34
Antibiotics: • Penicillin 50000-100000 u/kg/d tid-qid x
10days
Specific interventions:• hypertension• CHF• Furosemide 2mg/kg/dose/IV• Dialysis: if refractory indications: uremia,
intractable hyperK, CHF
MANAGEMENT
35
NORMAL BP VALUES
Age
NB8-30days1 mo – 2 yrs2-5y6-11y>12y
Upper limit
95 mmHg, systolic
105115/75130/80135/85140/90
36
PROGNOSIS
• complete resolution • 5-10% progress to chronic state
37
Mortality Rate:
• 0-7% due to sepsis, CHF, hypertensive enceph
38
Consultation with a pediatric nephrologist isnecessary when one or more of the following arepresent:
• Severe hypertension• Severe oliguria• Severe edema• Nephrotic-range proteinuria• Azotemia (moderate to marked)• Recurrent episodes of gross hematuria• Persistently depressed C3 (past 8-10 wk)
39
Consultation with a pediatric nephrologist is necessary when one or more of the following are present:
Atypical onset
• Absence of latent period• No evidence of streptococcal illness
40
Failure of expected resolution of clinical signs• Gross hematuria within the preceding 10-14
days• Microscopic hematuria within 1 year• Edema within 2 weeks• Proteinuria (>50 mg/dL) within 6 months• Azotemia within 1 week• Hypertension within 6 weeks
41
Consultation with a pediatric nephrologist is necessary when one or more of the following are present:
FOLLOW-UP
Further Inpatient Care
Only a small percentage of patients with acute glomerulonephritis (AGN) require initial hospitalization, and most of those are ready for discharge in 2-4 days.
42
Further Inpatient Care
As soon as the blood pressure (BP) is under relatively good control and diuresis has begun, most children can be discharged and monitored as outpatients.
43
Further Outpatient CareFollow up at 0-6 weeks as frequently as
necessary to determine the following:Hypertension has been controlled.Edema has started to resolve.Gross hematuria has resolved.Azotemia has resolved.
.
44
Follow up 8-10 weeks after onset to determine the following:Azotemia has subsided.Anemia has been corrected.Hypertension has resolved.C3 and C4 concentrations have returned
to normal.
45
Follow up at 3, 6, and 9 months after onset to check the following:Hematuria and proteinuria are subsiding
gradually.BP is normal.
46
Follow up at 2, 5, and 10 years after onset to check the following:Urine is normal.BP is normal.Serum creatinine level is normal
47
Follow up at 12 months after onset to determine the following:Proteinuria has disappeared.Microscopic hematuria has disappeared.
48
49