Glomerulonephritis in Children

GLOMERULONEPHRITIS IN CHILDREN
DEFINITION
Refers to group of generalized parenchimal diseases of mainly autoimmune

origin.
MAJOR CLINICAL MANIFESTATIONS GLOMERULONEPHRITIS

Acute nephritic syndrome Nephrotic syndrome Persistent urinary
abnormalities with few or no symptoms Chronic glomerulonephritis
14.2 ACUTE GLOMERULONEPHRITIS
Acute inflammation of the renal glomeruli.
Causes
• Immune reactions (usually 1-5 weeks after a streptococcal skin or throat

infection)
Clinical features
• Common in children >3 and adolescents

• Haematuria (passing smoky, red, or tea-coloured urine)
• Oedema: Puffiness of the face/around the eyes, less commonly generalized
body swelling
• Discomfort in the kidney area (abdominal or back pain)
• May be anorexia
• General weakness (malaise)
• High BP, commonly presenting as headaches, visual disturbances, vomiting,
and occasionally pulmonary
oedema with dyspnoea

• Convulsions (in hypertensive crisis)
• Oliguria as renal failure sets in
• Evidence of primary streptococcal infection:
-Usually as acute tonsillitis with cervical adenitis
-Less often as skin sepsis
Differential diagnosis
• Kidney infections, e.g. TB, pyelonephritis

• Kidney tumours
• Heart failure
• Malnutrition
• Allergic reactions
Investigations
 Urine: Protein, microscopy for RBCs and casts, WBCs

 Blood: Urea (uraemia) and creatinine levels, ASOT, electrolytes
 Ultrasound: Kidneys
 Throat & skin swab (where indicated): For C&S
Management HC4
 Monitor urine output, BP, daily weight

 Restrict fluid input (in oliguria)
 Restrict salt and protein in the diet (in oliguria)
 Avoid or use with caution any drugs excreted by the kidney (see section 14.8
Use of drugs in renal failure)
 Treat any continuing hypertension (refer to 18.8.4 Hypertension)
 Treat primary streptococcal infection (10-day course):
phenoxymethylpenicillin 500mg every 6 hours
Child: 10-20mg/kg per dose
 Or amoxicillin 500mg every 8 hours for 10 days Child: 15mg/kg per dose
If allergic to penicillin
 Erythromycin 500mg every 6 hours for 10 days
Child: 15mg/kg per dose
Note
 Ciprofloxacin, tetracycline, doxycyline, and cotrimoxazole are

unsuitable and should not be used for treating primary streptococcal
infection
Prevention
• Treat throat and skin infections promptly and effectively

• Avoid overcrowding
• Adequate ventilation in dwellings
14.3 NEPHROTIC SYNDROME
Disorder of the kidneys. Common in children and characterised, irrespective

of the cause, by:
• Generalised oedema
• Severe loss of protein in urine (proteinuria)
• Low protein (albumin) levels in the blood serum
(hypoalbuminaemia)
• Hyperlipidaemia (high blood cholesterol)
Causes
• Idiopathic/unknown (majority of cases)

• Congenital (rare)
• Secondary: Due to post-streptococcal acute glomerulonephritis, malaria,
allergy, UTI, hepatitis B, HIV
Investigations
As for Acute glomerulonephritis plus
 24 hour urine protein quantification

 Serum protein and cholesterol
• Cardiac failure
• Nutritional disorders causing low blood protein levels,
e.g. kwashiorkor
• Malabsorption syndrome
• Allergic states causing generalised body swelling
• Chronic glomerulonephritis
Management HC4
 Restrict salt intake (<2g daily, i.e. <half teaspoon/day)

 Restrict water/fluid intake
- Both salt and water/fluid intake should be continued until diuresis is

induced and swelling is subsiding which can take several weeks
If severe oedema
 Furosemide 40-80mg each morning to induce diuresis Child: 1-2mg/kg per

dose (but see notes below)
 Prednisolone 2mg/kg daily (max: 60mg)
-Continue until no further proteinuria (around 6 weeks)

-Gradually reduce the dose after the first 4 weeks,
e.g. reduce by 0.5mg/kg per day each week
When oedema has subsided and if still hypertensive

 Give appropriate treatment. See Hypertension If clinical signs of/suspected
infection:
 Give antibiotic as in Acute glomerulonephritis
If UTI suspected
 Treat as in 14.1 Acute cystitis
If patient from area of endemic schistosomiasis
 Praziquantel 40mg/kg single dose
If no improvement after 4 weeks or patient relapses
Refer for further management by Nephrologist

NEPHROTIC SYNDROME
Disorder of the kidneys. Common in children and characterised, irrespective

of the cause, by:
• Generalised oedema
• Severe loss of protein in urine (proteinuria)
• Low protein (albumin) levels in the blood serum
(hypoalbuminaemia)
• Hyperlipidaemia (high blood cholesterol)
Causes
• Idiopathic/unknown (majority of cases)

• Congenital (rare)
• Secondary: Due to post-streptococcal acute glomerulonephritis, malaria,
allergy, UTI, hepatitis B, HIV
Investigations
As for Acute glomerulonephritis plus
 24 hour urine protein quantification

 Serum protein and cholesterol
• Cardiac failure
• Nutritional disorders causing low blood protein levels,
e.g. kwashiorkor
• Malabsorption syndrome
• Allergic states causing generalised body swelling
• Chronic glomerulonephritis
Management HC4
 Restrict salt intake (<2g daily, i.e. <half teaspoon/day)

 Restrict water/fluid intake
- Both salt and water/fluid intake should be continued until diuresis is

induced and swelling is subsiding which can take several weeks
If severe oedema
 Furosemide 40-80mg each morning to induce diuresis Child: 1-2mg/kg per

dose (but see notes below)
 Prednisolone 2mg/kg daily (max: 60mg)
-Continue until no further proteinuria (around 6 weeks)

-Gradually reduce the dose after the first 4 weeks,
e.g. reduce by 0.5mg/kg per day each week
When oedema has subsided and if still hypertensive
 Give appropriate treatment. See Hypertension If clinical signs of/suspected

infection:
 Give antibiotic as in Acute glomerulonephritis
If UTI suspected
 Treat as in 14.1 Acute cystitis
If patient from area of endemic schistosomiasis
 Praziquantel 40mg/kg single dose
If no improvement after 4 weeks or patient relapses
Refer for further management by Nephrologist

1. 4. Pathogenesis of glomerulonephritis
2. 5. Sponsored Medical Lecture Notes – All Subjects USMLE Exam
(America) – Practice
3. 6. ETIOLOGY OF NEPHRITIC SYNDROMEETIOLOGY OF
NEPHRITIC SYNDROME • Post infectious glomerunephritis • Ig A-disease
• Henoch-Schon lein purpura
4. 7. Characteristics of acute nephriticCharacteristics of acute nephritic
syndromesyndrome HaematuriaHaematuria OliguriaOliguria
OedemaOedema  HypertensionHypertension Reduced glomerularReduced
glomerular filtration rate (GFR)filtration rate (GFR)  ProteinuriaProteinuria
Fluid overloadFluid overload
5. 8. Features of acute nephritic syndromeFeatures of acute nephritic syndrome
Haematuria is usually macroscopic with pink or brown urine (like coca-
cola) Oliguria may be overlooked or absent in milder cases Oedema is
usually mild or is often just peri-orbital- weight gain may be detected
Hypertension common and associated with raised urea and creatinine
Proteinuria is variable but usually less than in the nephrotic syndrome
6. 9. MANAGEMENT ISSUES IN THE NEPHRITICMANAGEMENT
ISSUES IN THE NEPHRITIC SYNDROMESYNDROME Skin and throat
swab Strep serology Evaluation of complement Urea, creatinine,
electrolytes, urinalysis BP Urine output and daily weight loss  Fluid
and diet management Treatment of infections
7. 10. COMLICATIONS OF NEPHRITIC SYNDROMECOMLICATIONS
OF NEPHRITIC SYNDROME Hypertensive encephalopathy (seizures,
coma) Heart failures (pulmonary oedema) Uraemia requiring
hemodialysis
8. 11. NEPHROTIC SYNDROMENEPHROTIC SYNDROME This is a group
of signs and symptoms seen in patients with heavy proteinuria Clinical
features:Clinical features: Oedema Proteinuria >3,5 g/24 hrs (> 0,05
g/kg/24 hrs) Serum albumen <30 g/l Hyperlipidemia and hypercoagulable
state
9. 12. Primary glomerular diseases causingPrimary glomerular diseases
causing the nephrotic syndromethe nephrotic syndrome o Minimal change
diseaseMinimal change disease o Focal and segmental
glomerulosclerosisFocal and segmental glomerulosclerosis o Membranous
glomerulonephritisMembranous glomerulonephritis o Proliferative
nephritis:Proliferative nephritis: o Membrano-proliferativeMembrano-
proliferative  Focal proliferativeFocal proliferative  Diffuse
proliferativeDiffuse proliferative  Mesangial proliferativeMesangial
proliferative
10. 13. Primary glomerular diseases causingPrimary glomerular diseases
causing the nephrotic syndrome (cont.)the nephrotic syndrome (cont.)
Systemic diseases: Diabetes mellitus HIV/AIDS SLE and other
connective tissue disorders Amyloidosis Nephrotoxic states: NSAIDS,
poisoning Allergic diseases: bee sting, pollens Circulatory effects: CHF,
constrictive pericarditis Neoplastic: leukemia, solid tumors
11. 14. MembranoproliferativeMembranoproliferative glomerulonephritis Type
Iglomerulonephritis Type I MembranousMembranous
glomerulonephritisglomerulonephritis
MembranoproliferativeMembranoproliferative glomerulonephritis Type
IIglomerulonephritis Type II
12. 15. Electron microscopyElectron microscopy of kidneys inof kidneys in
glomerulonephritisglomerulonephritis X-ray of healthy kidneys, ureters,
bladder
13. 16. MANAGEMENT OF PATIENTS WITHMANAGEMENT OF
PATIENTS WITH NEPHROTIC SYNDROMENEPHROTIC SYNDROME
Na+ <60 mmol/24 hrs Water restriction Diuretics (if no volume
depleted) Reduced protein diet (controversial!!!) Treatment of infections
Prevention of thrombosis Specific therapy: corticosteroids,
immunosupression For minimal change disease: prednisone forprednisone
for 16 weeks or prednisone+cyclophosphamide!!!16 weeks or
prednisone+cyclophosphamide!!!
14. 17. INDICATIONS FOR HEMODIALYSISINDICATIONS FOR
HEMODIALYSIS • Pericarditis or pleuritis (urgent indication) • Progressive
uremic encephalopathy or neuropathy, with signs such as confusion,
asterixis, myoclonus, wrist or foot drop, or, in severe cases, seizures (urgent
indication) • A clinically significant bleeding diathesis attributable to uremia
(urgent indication) • Fluid overload refractory to diuretics • Hypertension
poorly responsive to antihypertensive medications • Persistent metabolic
disturbances that are refractory to medical therapy; these include
hyperkalemia, metabolic acidosis, hypercalcemia, hypocalcemia, and
hyperphosphatemia • Persistent nausea and vomiting • Evidence of
malnutrition
15. 18. Peritoneal dialysisPeritoneal dialysis HemodialysisHemodialysis

Glomerulonephritis in Children

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GLOMERULONEPHRITIS IN CHILDREN

Refers to group of generalized parenchimal diseases of mainly autoimmune

MAJOR CLINICAL MANIFESTATIONS GLOMERULONEPHRITIS

14.2 ACUTE GLOMERULONEPHRITIS

Acute inflammation of the renal glomeruli.

• Immune reactions (usually 1-5 weeks after a streptococcal skin or throat

• Common in children >3 and adolescents

oedema with dyspnoea

• Kidney infections, e.g. TB, pyelonephritis

 Urine: Protein, microscopy for RBCs and casts, WBCs

 Monitor urine output, BP, daily weight

phenoxymethylpenicillin 500mg every 6 hours

Child: 10-20mg/kg per dose

 Erythromycin 500mg every 6 hours for 10 days

Child: 15mg/kg per dose

 Ciprofloxacin, tetracycline, doxycyline, and cotrimoxazole are

• Treat throat and skin infections promptly and effectively

14.3 NEPHROTIC SYNDROME

Disorder of the kidneys. Common in children and characterised, irrespective

• Hyperlipidaemia (high blood cholesterol)

• Idiopathic/unknown (majority of cases)

As for Acute glomerulonephritis plus

 24 hour urine protein quantification

 Restrict salt intake (<2g daily, i.e. <half teaspoon/day)

- Both salt and water/fluid intake should be continued until diuresis is

 Furosemide 40-80mg each morning to induce diuresis Child: 1-2mg/kg per

-Continue until no further proteinuria (around 6 weeks)

e.g. reduce by 0.5mg/kg per day each week

When oedema has subsided and if still hypertensive

 Treat as in 14.1 Acute cystitis

If patient from area of endemic schistosomiasis

 Praziquantel 40mg/kg single dose

If no improvement after 4 weeks or patient relapses

Refer for further management by Nephrologist

Disorder of the kidneys. Common in children and characterised, irrespective

• Hyperlipidaemia (high blood cholesterol)

• Idiopathic/unknown (majority of cases)

As for Acute glomerulonephritis plus

 24 hour urine protein quantification

 Restrict salt intake (<2g daily, i.e. <half teaspoon/day)

- Both salt and water/fluid intake should be continued until diuresis is

 Furosemide 40-80mg each morning to induce diuresis Child: 1-2mg/kg per

-Continue until no further proteinuria (around 6 weeks)

e.g. reduce by 0.5mg/kg per day each week

When oedema has subsided and if still hypertensive

 Give appropriate treatment. See Hypertension If clinical signs of/suspected

 Treat as in 14.1 Acute cystitis

If patient from area of endemic schistosomiasis

 Praziquantel 40mg/kg single dose

If no improvement after 4 weeks or patient relapses

Refer for further management by Nephrologist

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