Nephritic syndrome

Definition

Acute glomerular injury, defined by

• Hematuria (may be macroscopic) and RBC casts in urine
• Hypertension
• Oliguria and increasing creatinine
• Mild Proteinuria (not nephrotic range)
• Oedema

Causes of Nephritic syndrome

• Mostly post-infectious glomerulonephritis (80% post-streptococcal)
Membranoproliferative glomerulonephritis (MPGN) (closely related to infections)
• Lupus nephritis
• Haemolytic uaemic syndrome
• Vasculitides, such as Henoch Schönlein Purpura (IgA nephropathy)
• Sickle cell disease

Important points in history

• Preceding symptoms or illnesses (Infections, bloody diarrhea, joint pains, rash): In post-streptococcal GN usually 3-6 weeks before develpoment of kidney symproms
• Urine output and colour
• Abdominal pain
• Breathlessness, cough
• Headache, convulsions (hypertension)
• Past medical history of similar problem
• Family history of kidney diseases or hypertension

Important points on examination

• Blood pressure
• Baseline weight
• Edema and pulmonary edema
• Ascites
• Fever and signs of specific infections
• Consider Fundoscopy, if hypertensive

Investigations

• Blood pressure
• Urine dipstick and microscopy – Haematuria with red cell casts on microscopy, proteinuria and leucocyturia can be present
• FBC
• Creatinine and electrolytes, if possible
• Albumin
• HIV- test, Hepatitis B and C
• Sickle cell test
• Renal ultrasound and if remains hypertensive chest X-ray and Cardiac echo

Indications for admission

• Admit all children with an acute kidney injury for stabilization and investigations

Monitoring

• Blood pressure
• Weight
• Fluid chart: urine output and intake

Treatment

• Salt restriction
• Optimize fluid balance
Give Furosemide 1mg/kg IV, if moderate/ severe fluid overload and hypertension
• Treat blood pressure Start Nifedipine, if hypertensive
• Give stat dose Praziquantel
• When poststreptococcal glomerulonephritis is suspected, give penicillin or amoxicillin for 10 days
• If severe acute kidney injury develops, consider steroids (indicated in severe postinfectios GN, vasculitides and MPGN)
• If severe acute kidney injury develops, consider acute peritoneal dialysis (see protocol)

Prognosis

In post-streptococcal GN prognosis is usually good, hematuria may persist for months.

Follow-up

• In renal clinic until the child is normotensive without medications and urine dipstick and creatinine are normal