glomerulonephritis 10.05.2011

8/3/2019 Glomerulonephritis 10.05.2011

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Morning ReportRachel Laarman MD PGY-3


2/18

History 10 year old male with 4 day history of hematuria, described as bright

red or dark red, not cola colored. No dysuria, no frequency or urgency He also complains of some mild abdominal pain Parents have also been concerned that he has been puffy. They

describe his face as being very swollen, so bad his eyes were nearlyswollen shut and his lips were big. His belly seems more swollen aswell.

Mild diarrhea 4-5 days prior to presentation, which improved over2-3 days, none currently

Had cold symptoms 2-3 weeks prior to presentation

He was seen at an Urgent Care 2 days prior to admit diagnosedwith UTI and allergies and started on nitrofurantoin and givenbenadryl

Comes to ED for eval because he is not improving.


3/18

History ROS: No fever, no sore throat, no headaches, no

dizziness, no recent travel, no pets at home. No

vomiting, no nausea, no hematochezia.

PMH: Healthy, Imms UTD Fam Hx: Older brother has DiGeorge syndrome,

required cardiac surgery. No kidney disease orautoimmune disease in the family Social: Lives with parents and four sibs in SLC Meds: Nitrofurantoin

Allergies: NKDA


4/18

Physical Exam T 36.9. HR 60. RR 12. BP 139/92 R and 132/95 L. SaO2 95% on Room Air.WEIGHT - 38.2 Kg

GENERAL: well-appearing, lying in bed, NADHEAD: normocephalic, atraumatic.EYES: normal red reflex and pupillary reflexes bilaterally, extraocular movements intact,conjugate gaze, no conjunctival injection.EARS: tympanic membranes gray bilaterally, normal light reflex and landmarks, noeffusion or perforation.NOSE: no discharge or obstruction.

OROPHARYNX: moist mucus membranes, tonsils 2+ without exudate, no pharyngealerythema or lesions.NECK: No thyromegaly, supple without lymphadenopathy or tenderness to palpation.CARDIOVASCULAR: normal rate, normal rhythm, I/VI systolic murmur heard best atapex, normal pulses, capillary refill time


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Differential Time! What labs?

10 yo male with hematuria, hypertension, &edema


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Differential ListPrimary glomerulonephritis Secondary glomerulonephritis

Membranous

glomerulonephritis Membranoproliferative

glomerulonephritis type I

Membranoproliferativeglomerulonephritis type II(dense deposit disease)

IgA nephropathy Anti-glomerular basement

membrane disease

Idioapthic crscenticglomerulonephritis

Post-streptococcal

glomerulonephritis Other post-infectious

glomerulonephritis

Henoch-Schnlein purpuranephritis

Systemic lupus erythematosusnephritis

Microscopic polyangiitis

Wegener granulomatosus


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Labs CBC: WBC 9.5/ Hct 34/ Plt 248 UA: Sltly Cldy, Spec Grav:1.010, pH 7.0;

Glu/Ketones/Nitrites: Negative; HgB: Large; Protein:1+;

Leuk Est:Moderate; WBC >30, RBC >30, no bacteria CMP: Na 138, BUN 15,Cr 0.78, Alb 2.5 C3: 49 (70-206) C4: 20 ANA: Negative

dsDNA: Negative ASO: 727 (166-250 school-age children)

Urine cx from Urgent care: No growth


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Imaging

Renal U/S:

1. Right kidney at upper limits of normal size.Both kidneys areotherwise sonographically normal.2. Bilateral pleural effusions, right greater thanleft. Small

amount of free fluid in the right lower quadrant


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Post-Strep Glomerulonephritis

Hypertension, edema, proteinuria, hematuria M12 type most common cause of GN

Latent period is 1-2 weeks after infection toonset of GN

Immunoglobulins, complement present inglomerulus early in course lots of research has

looked for the nephritogenic antigen M Protein

Still controversy over true pathologicmechansim


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Microscopy

Hyperceullarity on H&E

Subepithelial deposits of IgG and C3Subepithelial humps

C3 is LowAcutePostStre

ptococcalGlo

erular

e

phriti


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12/18

Treatment

Antihypertensive is mainstay:

Loop diuretic + Na restriction

Calcium channel blockers

Question whether prompt treatment of strepinfection prevents PSGN, but unclear data


13/18

Follow-up

Follow C3 6 weeks out

Pt may have microscopic hematuria up to 1 yearfollowing diagnosis

If has a viral/mild infection shortly followingdiagnosis may develop gross hematuria


14/18

Prognosis

Typically very goodmost kids recover

(approx 90%)

However in more severe disease there can belingering symptoms for years.

hypertension


15/18

Summary

PSGN complication of GAS can also causeRheumatic fever and necrotizing fascitis

Majority of patients should have a full recovery

Need to repeat labs 6 weeks post-diagnosis


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References

Rudolphs Pediatrics. 2003. 21st Edition. McGraw-Hill Publishers.

Up to Date Herthelius, M. Renal function during and after acute

childhood poststreptococcal glomerulonephritis.Pediatr Nephrol (1999) 13:907911.

Eison, TM. Post-streptococcal acuteglomerulonephritis in children: clinical features andpathogenesis. Pediatr Nephrol (2011) 26:165180


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A 10-year-old girl presents with cola-colored urine and mild

swelling of her legs that she initially noticed 12 hours ago. Her

mother reports that she had a sore throat 10 days ago, and thechange in urine color occurred yesterday evening. There is no

history of trauma, and the patient denies flank pain, frequency,

urgency, dysuria, or passing clots in the urine. On physical

exam, her blood pressure is 144/90 mmHg, and she has mild

swelling of the face and lower extremities.

Of the following the MOST appropriate next step is

A. echocardiography

B. renal and bladder ultrasonography C. serum creatinine

D. throat swab for rapid streptococcal antigen

E. urine culture


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C. Serum Creatinine

First step in nephritic syndrome: check UA.

If hypocomplementemic, likely post-infectiousGN, need to assess renal function to determine ifchild warrants Nephrology consult and renalbiopsy.

glomerulonephritis 10.05.2011

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