Glomerulo-nephritis, acute poststreptococcal

Glomerulo-nephritis, acute poststreptococcal: Excerpt from Handbook of Diseases

Also called acute glomerulonephritis, acute poststreptococcal glomerlo-nephritis (APSGN) is a relatively common bilateral inflammation of the glomeruli. It follows a streptococcal infection of the respiratory tract or, less commonly, a skin infection such as impetigo.

APSGN is most common in males ages 6 to 10 but can occur at any age. Up to 95% of children and up to 70% of adults with APSGN recover fully; the remainder of patients may progress to chronic renal failure within months.

Causes

APSGN results from the entrapment and collection of antigen-antibody complexes (produced as an immunologic mechanism in response to streptococci) in the glomerular capillary membranes, inducing inflammatory damage and impeding glomerular function.

Sometimes the immune complement further damages the glomerular membrane. The damaged and inflamed glomerulus loses the ability to be selectively permeable and allows red blood cells (RBCs) and proteins to filter through as the glomerular filtration rate (GFR) falls. Uremic poisoning may result.

Signs and symptoms

APSGN begins within 1 to 3 weeks after untreated pharyngitis. Symptoms are mild to moderate edema, oliguria (less than 400 ml/24 hours), proteinuria, azotemia, hematuria, and fatigue.

Mild to severe hypertension may result from either sodium or water retention (due to decreased GFR) and inappropriate renin release. Heart failure from hypervolemia leads to pulmonary edema.

Diagnosis

A detailed patient history, assessment of clinical symptoms, and laboratory tests are needed to diagnose this disease. The following tests support the diagnosis:

❑ Urinalysis typically reveals proteinuria and hematuria. RBCs, white blood cells, and mixed cell casts are common findings in urinary sediment.

❑ Blood tests show elevated serum creatinine levels, low creatinine clearance, and impaired glomerular filtration.

❑ Elevated antistreptolysin-O titers (in 80% of patients), elevated streptozyme and anti-DNase B titers, and low serum complement levels verify recent streptococcal infection.

❑ Throat culture may also show group A beta-hemolytic streptococci.

❑ Renal ultrasonography may show a normal or slightly enlarged kidney.

❑ Renal biopsy may confirm the diagnosis in a patient with APSGN or may be used to assess renal tissue status.

Treatment

The goals of treatment are relief of symptoms and prevention of complications. Vigorous supportive care includes bed rest, fluid and dietary sodium restrictions, and correction of electrolyte imbalances (possibly with dialysis, although this is seldom necessary).

Therapy may include diuretics, such as metolazone and furosemide, to reduce extracellular fluid overload and an antihypertensive such as hydralazine. The use of antibiotics to prevent secondary infection or transmission to others is controversial.

Special considerations

❑ APSGN usually resolves within 2 weeks, so patient care is primarily supportive.

❑ Check vital signs and electrolyte values. Monitor intake and output and daily weight. Assess renal function daily through serum creatinine and blood urea nitrogen levels and urine creatinine clearance. Watch for signs of acute renal failure (oliguria, azotemia, and acidosis).

❑ Consult the dietitian to provide a diet high in calories and low in protein, sodium, potassium, and fluids.

❑ Protect the debilitated patient against secondary infection by providing good nutrition, using good hygienic technique, and preventing contact with infected people.

❑ Bed rest is necessary during the acute phase. Encourage the patient to gradually resume normal activities as symptoms subside.

❑ Provide emotional support for the patient and family. If the patient is on dialysis, explain the procedure fully.

❑ Advise the patient with a history of chronic upper respiratory tract infections to report signs of infection (fever, sore throat) immediately.

❑ Tell the patient that follow-up examinations are necessary to detect chronic renal failure. Stress the need for regular blood pressure, urinary protein, and renal function assessments during the convalescent months to detect recurrence. After APSGN, gross hematuria may recur during nonspecific viral infections; abnormal urinary findings may persist for years.

Clinical tip  Encourage pregnant women with a history of APSGN to have frequent medical evaluations because pregnancy further stresses the kidneys and increases the risk of chronic renal failure.

Book Source Details

• Book Title: Handbook of Diseases
• Author(s): Springhouse
• Year of Publication: 2003
• Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5

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