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Paediatrics: Glomerulonephritis
A combination of haematuria, oliguria, oedema, and hypertension with variable proteinuria.
Glomerulonephritis
A combination of haematuria, oliguria, oedema, and hypertension with variable proteinuria.
- Majority of cases post-infectious.
- Usually presents 1–2wks after a URTI and sore throat.
Causes of acute glomerulonephritis
Post-infectious
- Bacterial: streptococcal commonest, Staphylococcus aureus,
- Mycoplasma pneumonia, Salmonella
- Virus: herpesviruses (EBV, varicella, CMV)
- Fungi: candida, aspergillus
- Parasites: toxoplasma, malaria, schistosomiasis
Others (less common)
- MPGN
- IgA nephropathy
- Systemic lupus erythematosus
- Subacute bacterial endocarditis
- Shunt nephritis
Investigations
- Urine:
o urinalysis by dipstick: haematuria +/– proteinuria;
o microscopy—casts (mostly red cell casts).
- Throat swab: culture.
- Bloods:
o FBC;
o U&E, including creatinine, bicarbonate, calcium, phosphate, and
o albumin;
o ASOT/antiDNAase B;
o complement (expect low C3, normal C4);
o autoantibody screen (include ANA).
- Renal US (urgent).
- CXR (if fluid overload suspected).
Management
Most require admission because of fluid balance, worsening renal function, or hypertension. Treat life-threatening complications first:
- hyperkalaemia;
- hypertension;
- acidosis;
- seizures;
- hypocalcaemia.
Otherwise supportive treatment.
- Fluid balance:
- weigh daily;
- no added/restricted salt diet;
- if oliguric, fluid restrict to insensible losses (400mL/m2) + urine
- output;
- consider furosemide 1–2mg/kg bd if fluid overloaded.
- Hypertension:
o treat fluid overload;
o α-blockers and calcium channel blocker usual first choice;
o Note: Do not use ACE inhibitor (may worsen renal function).
- Infection: 10-day course of penicillin (does not affect natural history, but limits the spread of nephritogenic bacterial strains).
When to refer to paediatric nephrology unit
- Patients with life-threatening complications (see Management).
- Those with atypical features, including:
- worsening renal function;
- nephrotic state;
- evidence of systemic vasculitis (e.g. rash);
- normal C3 complement levels;
- increased C4 complement levels;
- +ve ANA;
- persisting proteinuria at 6wks;
- persisting low C3 at 3mths.
Prognosis
- 95% with post-streptococcal glomerular nephritis (GN) show complete recovery.
- Microscopic haematuria may persist for 1–2yrs.
- Discharge from follow-up once urinalysis, BP, and creatinine are normal.