Introduction

Inflammation and proliferation of glomerulus caused by imunological

process, with history of prior streptococcal infection

Management mainly supportive Prognosis was excellent in most cases,

but remains an important causes of AKI in developing countries

APSGN

Iturbe BR, Mezzano S. Acute post infectious glomerulonephritis . Pediatric Nephrology. 2008Eison M. T, Ault H.B. Post-streptococcal acute glomerulonephritis in children : clinical feature and pathogenesis.

Pediatr Nephrol. 2011Rauf S, Albar H, Aras J. Konsensus glomerulonefritis akut pasca streptokokus.IDAI. 2012

Most common form of acute nefritic syndrome

ETIOLOGYStreptokokus β-

hemolitikus grup A (SBHGA) nefritogenic

strain

Serotipe associated with URI : M types

1,3,4,12,49

Serotipe associated with pyodermitis :

M types 2,49,55,57,60

.•Pardede SO. Struktur sel streptokokus dan patogenesis glomerulonefritis akut pascastreptokokus. Sari Pediatri. 2009. h 56-65.

•Rodriguez B, Musser J. J Am Soc Nephrol 2008.

CLINICAL MANIFESTATION

ANS

Hematuria

Edema

HypertensionProteinuria

Decreased GFR

Eison M. T, Ault H.B. Post-streptococcal acute glomerulonephritis in children : clinical feature and pathogenesis. Pediatr Nephrol. 2011;26:165-80.

Urine

Gross Hematuria in Children

APSGN

•Abdominal pain, joint pains, rash, arthralgia

Henoch Schonlein Purpura

•Recurrent, painless gross hematuria

IgA Nephropathy

•Fever, weight loss, fatigue, arthritis

SLE

•Family history of renal disease that led to ESRD

Alport Syndrom

Welch TR. An approach to the child with acute glomerulonephritis, review article. Int J Pediatr. 2012;3:1-3.

CLINICAL MANIFESTATION

.

3 Phases

Latent phase

Acute phase

Recovery phase

Eison M. T, Ault H.B. Post-streptococcal acute glomerulonephritis in children : clinical feature and pathogenesis. Pediatr Nephrol. 2011;26:165-80.

1-2 weeks in upper respiratory infection3-6 weeks in skin infection (pioderma) 6-8 weeks

After resolution of overload, along with n BP, resolution of proteinuria, and gross hematuria

CLINICAL MANIFESTATION

. Eison M. T, Ault H.B. Post-streptococcal acute glomerulonephritis in children : clinical feature and pathogenesis. Pediatr Nephrol. 2011;26:165-80.

DIAGNOSIS

•History of antecendent upper respiratory tract or skin infectionHistory

•Acute nephritic syndromeClinical

manifestations

•RBCs, frequently in asscociation with RBC casts, proteinuria, leukosituriaUrinalysis

•ASO ↑, antihialurodinase

•C3 ↓ and normal C4

•Pharyngeal swab culture Laboratorium

•Usually not indicatedBiopsy

Behrman RE, Kliegman R. Acute postreptococal glomerulonephritis. Dalam : Nelson’s Essentials of Pediatrics. Philadelpia : WBSaunders and company; 2004. hal 1740-1.

MANAGEMENT

•Treat the acute effect of renal insufficiency and hypertension

Goals Supportive

Salt restictionand loop diuretic

Antihypertension Antibiotic

Behrman RE, Kliegman R. Acute postreptococal glomerulonephritis. Dalam : Nelson’s Essentials of Pediatrics. Philadelpia : WB Saunders and company; 2004. hal 1740-1.

COMPLICATIONS

• hypertensive encephalopathy

• acute lung edema

• acute renal failure

Albar H, Rauf S. The profile of acute glomerulonephritis among Indonesian Children. Paediatr

Indones. 2005;45:264–9.

Management of hypertensive crisis

Nifedipine

• 0.1-0.5 mg/kg sublingual, with a maximum total dose of 10 mg

• Can be repeated every30 minutes

• Onset within 1-5 minutes

• Side effect: precipitous fall of BP

The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents, Pediatrics 2004

Management of hypertensive crisis

Clonidine

• 0.002 mg/kg/dose IV slow – 4 times a day

Can be increased up to 0.006 mg/kg/dose

• Onset: 5 minutes

• Duration: few hours

• Side effect: rebound hypertension

• 5-10 mcg/kg/day oralThe Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents, Pediatrics 2004

Management of hypertensive crisis

Nicardipine

• 1-5 mcg/kg/min as a continuous infusion

• Very rapid onset of action, within few minutes

• Short duration of action, half-life 40 minutes

The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents, Pediatrics 2004

Management of hypertensive crisis

Sodium nitoprusside

• 0.5-10 mcg/kg/min IV drip

• Onset within 2 minutes

• Duration < 10 minutes

The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents, Pediatrics 2004

• Excellent

• Survival rate up to 95% in APSGN cases

• Only 1% will become RPGN

• Low recurrent rate but might happen ec other nephrogenic strain of Streptococcus

PROGNOSIS

Kasahara T, Hayakawa H, Okubo S. Okugawa T. Kabuki N. Tomizawa S, dkk. Prognosis of acute poststreptococcalglomerulonephritis is excellent in children, when adequately diagnosed. Pediatr Int. 2001;43:364-67.

TAKE HOME MESSAGES

• Exclude diseases other than glomerulonephritis.

• The presence of a post- infectious process is suggested by a clinical history of infection, laboratory evidence of recent infection, and the presence of transiently decreased activation of complement via the alternative pathway.

• If the diagnosis remains inconclusive, biopsy can aid the final inference.

Thank You