gnaps online simpo rev 2

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  • 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 -

    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 : Nelsons 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 : Nelsons 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;45:2649.

  • 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