Preceptor: dr. Ulinar M., Sp.

A
Compiled by: Michael S. Rampangilei 07120080106
FACULTY OF MEDICINE UNIVERSITY OF PELITA HARAPAN DEPARTMENT OF PEDIATRICS CLINICAL CLERKSHIP BHAYANGKARA TK. 1 R. SAID SUKANTO HOSPITAL DECEMBER 23RD-MARCH 1ST 2014 PERIOD

IDENTITY
Name Gender Age Address Weight Height Date of admission Date of examination :N : Male : 10 Years 6 Months : Cigudeg : 29kg : 130cm : 22nd December 2013 : 22nd December 2013

ANAMNESIS

Chief and additional complaints

Auto- and alloanamnesis to the patient and his mother Chief Complaint Hip pain since 9 days before hospital admission Additional Complaint Abdominal pain, nausea, vomiting, fever, constipation, both eyes swollen

History of the present illness

The patient complained of a dull pelvic pain that started 9 days before being admitted to the hospital. The pain radiates towards the front central torso. 6 days before hospital admission, the patient woke up with both eyelids swollen and complained of a blurry vision. Patient was taken to RS MISI diagnosed with Acute Glomerulonephritis and undefined eye illness. The patient consulted with an ophthalmologist but no pathologies were discovered. During urination, the color was dark tea like, no pain is evident. The patient has also experienced nausea and frequent vomiting 4- 5x/day since the initial symptom. A day before the pelvic pain, the patient endured a constant fever recorded by the mother at 38,8C, that was relieved by consuming paracetamol temporarily. The last time the patient defecated was 3 days before being admitted. The patient suffered a cough and runny nose 2 days before hospital admission. The patient said that he didnt consume any drugs before the onset of his sickness and he doesnt have any allergy to some food or medicine. There werent any patients family, relatives, or friends who had the same symptoms.

Past diseases history

Pharyngitis/tonsillitis: (+) Bronchitis Pneumonia : (-) : (-) Basilar dysentriae : (-) Amoeba dysentriae Typhoid Abdomen Parasite Operation Brain injury Fracture Medicine Allergies : (-) Others : (-) : (-) : (-) : (-) : (-) : (-) : (-) :-

Morbili
Pertussis Varicela

: (+)
: (-) : (-)

Diphteriae
Malaria Polio Enteritis

: (-)
: (-) : (-)

Family History
Parents married: once for a mother, once for a father Patients father is healthy Patients mother is healthy People surrounding the patient is healthy History of siblings
Year 2003 Gestational age 9 months Method of delivery Normal Sex Male Birthweight 3000 gram

Past obstetric state

Prenatal care
Antenatal care is done regularly at the local clinic Sickness while pregnant: -

Pregnancy history
Gestational age: 40 weeks (normal) Born at Home Delivered by a midwife Born by normal delivery, cried directly after delivery Weight: 3000 gram (normal: 2500-4000 gram) Height: 49cm (normal: 45-54 cm)

Growth and developmental state

Vaccination
BCG Varicella DPT Polio Hepatitis B Measles Other vaccinations : 1x : 0x : 3x : 4x : 3x : 2x :-

Patients been given fundamental vaccination according to the governments law.

Food intake
Breastfeeding since born until 9 months old Started be given formula milk since the age of 10 months. The milk was dancow. Fruits have been given since the age of 10 months (banana and papaya) Vegetables been given since the age of 10 months (carrot and celery) Condensed food been given since the age of 1,5 year old (rice, egg, beef meat, chicken meat, and fish). Quantity and quality of the food intake, in overall is considered as sufficient

PHYSICAL EXAMINATION
Done on December 22rd 2013 (1st day of medical care)

Vital signs
General condition Level of consciousness Blood Pressure Pulse Rate Respiratory Rate Axillary temperature : Patients looks moderately ill :Compos Mentis, GCS 15 (E4M6V5) : 150/80 mmHg : 90x/minute, regular, adequate : 22x/minute : 36,7C

Nutritional status
Weight Height Weight for Age Height for Age 94,90% Weight for Height : 29 kg : 130 cm : 29/30= 96,67% : 130/137 = : 29/ 27= 107,41%

Interpretation

: Normoweight

General examination
Head :
Normocephaly Deformity (-)

Eyes

Pale conjunctiva -/Icteric sclera -/Secretions -/Pupil is rounded, isochore 3mm/3mm Direct light reflex +/+ Indirect light reflex +/+ Edema Palpebra +/+

Nasal:
Septum is in the middle, deviation (-) Secretions -/ Nasal flaring -/-

 Ear:
External acoustic meatus +/+ Timpanyc membrane is intact +/+ Cerumen -/Secretions -/Wet lips Oral mucous is wet, kopliks spot (-) Tongue is wet, coated tongue (-) Pharyx is hyperemic (+) Tonsil is T2/T3

Mouth :

Neck :
Intact trachea in the middle Mass (-) Enlarged lymph nodes (-)

 Thorax
Pulmo Inspection: symmetrical breathing movements Palpation: Stem fremitus on the right and the left were equivalent Percussion: Sonor in both lungs field Ausculation: Vesicular breath sound +/+, wheezing -/, rhonchi -/ Cardio Inspection : Ictus cordis was unseen Palpation : Ictus cordis was palpated on the 5th intercostal left midclavicular line Percussion : Cardiomegaly (-) Auscultation : S1 and S2 regullar, gallop (-), murmur (-)

 Abdomen
Inspection: Flat abdomen Auscultation: Bowel sound (+) 2-3x/minute Palpation: Tenderness (-), hepatomegaly (-), splenomegaly (-), muscular defense (-) Percussion: Timpany on all abdominal region

Extremities :
Warm Capillary refill time < 3 seconds Edema (-)

LABORATORY S EXAMINATION

December 18th 2013

Examination Hematology I Hemoglobin Hematocrit Leukocyte Thrombocyte SGOT SGPT Hitung Jenis Basophil Eosinophil Batang Segmen Limfosit Monosit 0 0 0 63 25 12 % % % % % % 0-1 1-3 2-6 50-70 20-40 0-1 10,7 31 9,200 242.000 23 10 g/dl % /L L /L /L Boy : 13-18; Girl : 12-16 Boy : 40-58; Girl : 37-43 5.000-10.000 150.000-500.000 Result Unit Normal Value

Examination Urinalysis Color Clearity pH Weight Protein Bilirubin Glucose Keton Blood/ Hb Nitric Urobilinogen Leukocyte Sediment Leukocyte Erithrocyte Epithelial cells Cyclinder Crystal Others

Result

Unit

Normal Value

Yellow Cloudy 5.5 1.025 +3 +1 + +1 0,1 IU 5.5-8.5 1.000-1.030 Negative Negative Negative Negative Negative Negative 0,1-1,0 Negative

6-7 7-14 5-8 +amorf -

/ 40x FOV / 40x FOV / 40x FOV / 40x FOV / 40x FOV

Negative Negative Negative Negative Negative Negative

December 22nd 2013

Examination Hematology I Hemoglobin Hematocrit Leukocyte Thrombocyte Erythrocyte
Examination Clinic Chemistry Ureum Creatinine 125 2,2 mg/dl mg/dl mg/dl 10 - 50 0,5 1,5 <200

Result

Unit

Normal Value

11,5 33 7.600 361.000 4.38

Result

g/dl % /L /L

Boy : 13-18; Girl : 12-16 Boy : 40-58; Girl : 37-43 5.000-10.000 150.000-500.000

Million/ul 4.5-5.5
Unit Normal Value

Random Blood Glucose 114

December 23rd 2013

Examination Complete Feces Exam Color Consistency Mucus Blood Microscopic Leukocyte Erythrocyte +1-2 0-1 Negative Negative Brown Soft Result Unit Normal Value

Examination Hematology III Hemoglobin Hematocrit Leukocyte Thrombocyte LED Hitung Jenis Basophil Eosinophil Batang Segmen Limfosit Monosit

Result

Unit

Normal Value

10,7 30 7,700 342.000 60

g/dl % /L L %

Boy : 13-18; Girl : 12-16 Boy : 40-58; Girl : 37-43 5.000-10.000 150.000-500.000 <15

0 5 0 61 31 3

% % % % % %

0-1 1-3 2-6 50-70 20-40 0-1

Examination Liver Funtion Test Total Protein Albumin Globulin Bilirubin Total Bilirubin Direct Indirect Bilirubin SGOT SGPT Lemak Lengkap Total Cholesterol HDL LDL Tryglyceride Ureum Creatinine Electrolytes Sodium Potassium Chloride

Result

Unit

Normal Value 6.0 8.7 3.5 5.2 2.5 3.1 <1.5 <0.5 <1.0 <37 <40

30 2,2 2,6 0,20 0,07 0,13 71,4 50,1

g/dl g/dl g/dl Mg/dL Mg/dL Mg/dL L L

156 18 90 242 172 1,8

Mg/dL Mg/dL Mg/dL Md/dL Mg/dL Mg/dL

<200 35 - 55 <160 <200 10 50 0,5 1,8

132 4,4 106

Mmol/L Mmol/L Mmol/L

135 145 3,8 5,0 98 - 106

Examination Urinalysis Color Clearity pH Weight Protein Bilirubin Glucose Keton Blood/ Hb Nitric Urobilinogen Leukocyte Sediment Leukocyte Erithrocyte Epithelial cells Cyclinder Crystal Others

Result

Unit

Normal Value

Yellow Cloudy 5.5 1.020 +3 + +2 0,1 IU 5.5-8.5 1.000-1.030 Negative Negative Negative Negative Negative Negative 0,1-1,0 Negative

4-5

/ 40x FOV

Negative

21-23

/ 40x FOV

Negative

/ 40x FOV

Negative

Granular 1 -2

/ 40x FOV

Negative

/ 40x FOV

Negative

Negative

December 26th 2013

Examination Hematology I Hemoglobin Hematocrit Leukocyte Thrombocyte Ureum Creatinine 10,4 31 13.600 284.000 47 0,9 g/dl % /L /L Boy : 13-18; Girl : 12-16 Boy : 40-58; Girl : 37-43 5.000-10.000 150.000-500.000 Result Unit Normal Value

Mg/dL 10 - 50 Mg/dL 0,5 1,5

26th of December 2013

RESUME

 A 10 years 6 months old boy patient, came to the emergency department of Polri Hospital on December 20th 2013 with the chief complaint of a dull pelvic pain that started 9 days before being admitted to the hospital. The pain radiates towards the front central torso. Both of the patients eyelids swollen and caused a blurry vision. The patients urine color was dark tea like. The patient has also experienced nausea and frequent vomiting 45x/day since the initial symptom. A fever recorded by the mother at 38,8C, that was relieved by consuming paracetamol temporarily. Patient also presented with constipation. The patient suffered a cough and runny nose 2 days before hospital admission.

 Physical examination on December 23rd 2013: General condition moderately ill Level of consciousness (E4M6V5) Blood Pressure Pulse Rate adequate Respiratory Rate Axillary temperature Further examination: Laboratory shows hyperurecemia, increased LFT, micro hematuria, proteinuria, Hypertryglyceride : Patients looked :Compos Mentis, GCS 15 : 150/80 mmHg : 90x/minute, regular, : 22x/minute : 36,7C

DIAGNOSIS
A 10 years 6 months old boy patient, with weight 29 kg, and height 130 cm, been sick for 8 days, and receiving his 4th day of medical care, with working diagnosis of:

Acute Glomerulonephritis with Secondary Hypertension

Acute Tonsillopharyngitis Growth and development is appropriate with age Fundamental vaccination have been completely given

TREATMENT
IVFD Ringer Lactate maintenance 2000 cc/24jam Cefotaxime IV 2x750mg Lasix tablet 1x30mg Captopril 2 x 5mg

PROGNOSIS
Quo ad vitam Quo ad functionam Quo ad sanationam : Dubia ad Bonam : Dubia ad Bonam : Dubia

FOLLOW-UP
2
ND

day of medical care

S O

Fever (-), eyelids are still swollen and still the complain of nausea General condition : Patient looked moderately ill

Level of consciousness: Compos Mentis, GCS 15 (E 4M6V5) Blood Pressure Pulse Rate Respiratory Rate : 140/90 mmHg (Normal: 100-120/60-75) : 90x/minute, regular, adequate (Normal :60-100x/minute) : 22x/minute (Normal: 16-20x/minute)

Axillary temperature : 36,8C A P 10

th

day of acute glomerulonephritis IVFD Ringer Lactate maintenance 2000 cc/24jam Cefotaxime IV 2x750mg Lasix tablet 1x30mg Captopril 2 x 5mg

3RD day of medical care

S O

Fever (-), eyelids are still swollen, fullness of the abdomen General condition : Patient looked moderately ill

Level of consciousness: Compos Mentis, GCS 15 (E 4M6V5) Blood Pressure Pulse Rate Respiratory Rate : 130/80 mmHg (Normal: 100-120/60-75) : 70x/minute, regular, adequate (Normal :60-100x/minute) : 20x/minute (Normal: 16-20x/minute)

Axillary temperature : 36C Extremities A P 11

th

: Swollen lower extremities

day of acute glomerulonephritis Released from the hospital IVFD Ringer Lactate maintenance 2000 cc/24jam Cefotaxime IV 2x750mg Lasix tablet 1x30mg Captopril 2 x 5mg

4th day of medical care

S O

Fever (-), eyelids are still swollen, fullness of the abdomen, shortness of breath General condition : Patient looked moderately ill

Level of consciousness: Compos Mentis, GCS 15 (E4M6V5) Blood Pressure Pulse Rate Respiratory Rate : 110/70 mmHg (Normal: 100-120/60-75) : 88x/minute, regular, adequate (Normal :60-100x/minute) : 28x/minute (Normal: 16-20x/minute)

Axillary temperature : 36,5C Abdomen A P

th

: Shifting Dullness (+)

12 day of acute glomerulonephritis

IVFD Ringer Lactate maintenance 2000 cc/24jam Cefotaxime IV 2x750mg Lasix tablet 1x30mg Captopril 2 x 5mg

5 day of medical care

th

S O

Fever (-), eyelids are still swollen, General condition : Patient looked moderately ill

Level of consciousness: Compos Mentis, GCS 15 (E4M6V5) Blood Pressure Pulse Rate Respiratory Rate : 100/60 mmHg (Normal: 100-120/60-75) : 80x/minute, regular, adequate (Normal :60-100x/minute) : 24x/minute (Normal: 16-20x/minute)

Axillary temperature : 36C A P 13 day of acute glomerulonephritis

th

IVFD Ringer Lactate maintenance 2000 cc/24jam Cefotaxime IV 2x750mg Lasix tablet 1x30mg Captopril 2 x 5mg

6 day of medical care

th

S O

Headache and Fatigued General condition : Patient looked moderately ill

Level of consciousness: Compos Mentis, GCS 15 (E4M6V5) Blood Pressure Pulse Rate Respiratory Rate : 160/90 mmHg (Normal: 100-120/60-75) : 84x/minute, regular, adequate (Normal :60-100x/minute) : 20x/minute (Normal: 16-20x/minute)

Axillary temperature : 37C A P 14 day of acute glomerulonephritis

th

IVFD Ringer Lactate maintenance 2000 cc/24jam Cefotaxime IV 2x750mg Lasix tablet 1x30mg Captopril 2 x 5mg

Albumin 20% 50cc

7 day of medical care

th

S O

Headache General condition : Patient looked mildly ill

Level of consciousness: Compos Mentis, GCS 15 (E4M6V5) Blood Pressure Pulse Rate Respiratory Rate : 130/80 mmHg (Normal: 100-120/60-75) : 80x/minute, regular, adequate (Normal :60-100x/minute) : 20x/minute (Normal: 16-20x/minute)

Axillary temperature : 36,6C A P 15

th

day of acute glomerulonephritis IVFD Ringer Lactate maintenance 2000 cc/24jam Cefotaxime IV 2x750mg Lasix tablet 1x30mg Captopril 2 x 5mg

8 day of medical care

th

S O

General condition : Patient looked mildly ill

Level of consciousness: Compos Mentis, GCS 15 (E4M6V5) Blood Pressure Pulse Rate Respiratory Rate : 120/90 mmHg (Normal: 100-120/60-75) : 76x/minute, regular, adequate (Normal :60-100x/minute) : 20x/minute (Normal: 16-20x/minute)

Axillary temperature : 36C A P 16 day of acute glomerulonephritis

th

IVFD Ringer Lactate maintenance 2000 cc/24jam Cefotaxime IV 2x750mg Lasix tablet 1x30mg Captopril 2 x 5mg

9th day of medical care

S O

General condition : Patient showed substantial improvement than the day before

Level of consciousness: Compos Mentis, GCS 15 (E4M6V5) Blood Pressure Pulse Rate Respiratory Rate : 110/80 mmHg (Normal: 100-120/60-75) : 88x/minute, regular, adequate (Normal :60-100x/minute) : 20x/minute (Normal: 16-20x/minute)

Axillary temperature : 36,3C A P Released from the hospital

Acute Glomerulonephritis

Background

Definition:
The failure of kidneys to process and regulate its physiological function due to the immunologic mechanism that triggers inflammation and proliferation of glomerular tissue which in turn result in the damage to the basement membrane, mesangium, or capillary endothelium.

Hippocrates originally described the manifestation of back pain and hematuria, which lead to oliguria or anuria. With the development of the microscope, Langhans was later able to describe these pathophysiologic glomerular changes. Acute GN is defined as the:
Sudden onset of hematuria Proteinuria, and Red Blood Cell (RBC) casts

Fundamental Kidney Anatomy and Function

 8 fundamental function of the Kidneys:

Excretion of Metabolic Waste and Foreign Substances Regulation of Water and Electrolyte Balance Regulation of Extracellular Fluid Volume Regulation of Plasma Osmolality Regulation of Red Blood Cell Production

Regulation of Vascular Resistance

Regulation of Acid-base Balance Regulation of Vitamin D Production Gluconeogenesis

Etiology

Infectious Non-Infectious Primary Renal Disease Streptococcus species (ie, group A, betahemolytic) Membranoproliferative Glomerulonephritis Serotype 12 - upper respiratory infection Serotype 49 - skin infection Berger Disease Staphylococci Pure Mesangial Proliferation Mycobacteria Systemic Disease HSP Brucella suis Vasculitis (Wegener Granulomatosis) Treponema pallidum SLE Corynebacterium bovis Polyarteritis nodosa CMV Goodpasture Syndrome EBV
Miscellaneous Disease

Guillain-Barr syndrome Irradiation of Wilms tumor Diphtheria-pertussis-tetanus (DPT) vaccine

Pathophysiology
fPSGN Formation of Immune Complexes

NPSGN

Inflamation of Glomerular tufts

Endothelial, Epithelial, Mesangial Cellular Proliferation

Glomeruli Deposition Extracapillary

50% Kidney Enlargement

Endocapillary Glomerular Basement Thickening

Increased number of cells in Glomerular tufts

Hyalinization/Scl erosis

Glomeruli Deposition

DIAGNOSIS

Disease Presentation
HISTORY Identification of an underlying systemic disease (if any) or recent infection. Use of intravenous medications
Triad of sinusitis, pulmonary infiltrates, and nephritis Wegener granulomatosis

Nausea and vomiting, abdominal pain, and purpura, HenochSchnlein purpura

Arthralgias, associated with systemic lupus erythematosus (SLE) Hemoptysis, occurring with Goodpasture syndrome or idiopathic progressive glomerulonephritis

Skin rashes, observed with hypersensitivity vasculitis or SLE

 Risk Factor: Male, aged 2-14 years, who suddenly develops puffiness of the eyelids and facial edema in the setting of a poststreptococcal infection. Urine:
Dark and scanty

Blood pressure may be elevated.

Nonspecific symptoms:
Weakness, Fever Abdominal pain Malaise

Onset and duration of the illness:

Symptom onset is usually abrupt. The onset of nephritis within 1-4 days of streptococcal infection

Assess the consequences of the disease process (uremic symptoms):

Inquire about loss of appetite, Generalized itching and tiredness, Nausea Easy bruising Nosebleeds Facial swelling Leg edema Shortness of Breath

 Inquire about symptoms of acute glomerulonephritis, including the following:

Hematuria (smoky-, coffee-, or cola-colored urine) Oliguria Edema (peripheral or periorbital) - This is reported in approximately 85% of pediatric patients; edema may be mild (involving only the face) to severe, Headache - This may occur secondary to hypertension; confusion secondary to malignant hypertension may be seen in as many as 5% of patients. Shortness of breath or dyspnea on exertion - This may occur secondary to heart failure or pulmonary edema; it is usually uncommon, particularly in children. Possible flank pain secondary to stretching of the renal capsule

PHYSICAL EXAMINATION

Patients present with a combination of edema, hypertension, and oliguria.

The physician should look for the following signs of fluid overload:
Periorbital and/or pedal edema Edema and hypertension due to fluid overload (in 75% of patients) Crackles (ie, if pulmonary edema) Elevated jugular venous pressure Ascites and pleural effusion (possible)

 The physician should also look for the following:

Rash (as with vasculitis, Henoch-Schnlein purpura, or lupus nephritis) Pallor Renal angle (ie, costovertebral) fullness or tenderness, joint swelling, or tenderness

Hematuria, either macroscopic (gross) or microscopic

Abnormal neurologic examination or altered level of consciousness (from malignant hypertension or hypertensive encephalopathy) Arthritis

 Other signs include the following:

Pharyngitis Impetigo Respiratory infection Pulmonary hemorrhage Heart murmur (possibly indicative of endocarditis) Scarlet fever Weight gain Abdominal pain Anorexia Back pain Oral ulcers

Progression of Disease
Progression to sclerosis is rare in the typical patient
0.5-2% of patients with acute GN, the course progresses toward renal failure, resulting in kidney death in a short period.

Abnormal urinalysis (ie, microhematuria) may persist for years. Marked decline in the glomerular filtration rate (GFR) is rare. Pulmonary edema and hypertension may develop. Generalized anasarca and hypoalbuminemia may develop secondary to severe proteinuria. End-organ damage in the central nervous system (CNS) or the cardiopulmonary system can develop in patients who present with severe hypertension, encephalopathy, and pulmonary edema. Those complications include the following:
Hypertensive retinopathy Hypertensive encephalopathy Rapidly progressive GN Chronic renal failure Nephrotic syndrome

Workup
Complete Blood Count Streptozyme Tests Urinalysis and Sediment Blood and Tissue Culture Blood Urea Nitrogen NAPR

Serum Ureum and Creatinine

Electrolytes

Renal Biopsy

Erythrocyte Sedimentation Rate

Ultrasonography

Differential Diagnosis
The following 4 renal syndromes commonly mimic the early stage of acute glomerulonephritis (GN):
Anaphylactoid purpura with nephritis Chronic GN with an acute exacerbation Idiopathic hematuria Familial nephritis

 Immunoglobulin A (IgA) nephritis

The latent period between infection and onset of nephritis is 1-2 days Nephritis may be concomitant with upper respiratory tract infection

Lupus nephritis
Gross hematuria is unusual in lupus nephritis.

GN of chronic infection
Manifest as acute nephritis

Unlike PSGN, in which the infection may have resolved by the time nephritis occurs, patients with nephritis of chronic infection have an active infection at the time nephritis becomes evident.
Circulating immune complexes play an important role in the pathogenesis of acute GN in these diseases.

Management

Key Concept SUPPORTIVE THERAPY.

Pharmacological Agents Antibiotics Diuretics Antihypertensives/Vasodilator Drugs Glucocorticoids Diet and Activity Sodium and fluid restriction

Protein restriction for patients with * no evidence of no malnutrition

Bed rest is recommended until signs of glomerular inflammation and circulatory congestion subside.

Antibiotics
Penicillin V(500 mg PO q12hr or 250 mg PO q6hr for 10 days)
250 mg of penicillin V = 400,000 U of penicillin.

Cephalexin (25-50 mg/kg/day PO divided q6-8hr for 10 days; 4 g/day maximum)

The recommended dosing schedule of erythromycin may result in GI upset, causing one to prescribe an alternative macrolide or to change to thrice-daily dosing. Erythromycin covers most potential etiologic agents, including mycoplasmal species.

Erythromycin (Mild-to-moderate infections: 30-50 mg/kg/day PO divided q6-12hr, Severe infection: 60-100 mg/kg/day PO divided q6-12hr)
In children, age, weight, and severity of infection determine the proper dosage. When twice-daily dosing is desired, half the total daily dose may be taken every 12 hours. For more severe infections, double the dose. Erythromycin has the added advantage of being a good anti-inflammatory agent by inhibiting the migration of polymorphonuclear leukocytes.

Loop Diuretics
Loop diuretics decrease plasma volume and edema by causing diuresis. The reductions in plasma volume and stroke volume associated with diuresis decrease cardiac output and, consequently, blood pressure.
Furosemide (Lasix) Initial Dosage: 1 2mg/kg/hr (PO/IV) Increased Dosage: 1 2mg/kg/6 8hr (PO) OR 1mg/kg/ 2hr (IV) Maximum Dose: 6mg/kg/day Increases excretion of water by interfering with the chloride-binding cotransport system, inhibiting sodium and chloride reabsorption in the ascending loop of Henle and the distal renal tubule. Rapidly absorbed from the gastrointestinal (GI) tract. The diuretic effect is apparent within 1 hour of oral (PO) administration and lasts for 4-6 hours. After intravenous (IV) administration, diuresis occurs within 30 minutes; the duration of action is about 2 hours

Antihypertensives
Amlodipine (6 years: 2.5-5 mg/day PO) Labetalol (0.4-1 mg/kg/hr by continuous IV infusion; not to exceed 3 mg/kg/hr) Nifedipine (0.25-0.5 mg/kg/day (extended release) PO in 1 or 2 daily doses initially; not to exceed 3 mg/kg/day (120 mg/day) Hydralazine (Maximum dose in children: 7.5 mg/kg/day divided q12hr PO) Nitroprusside 10 mcg/kg/min (6 mcg/kg/min in neonates)

Prognosis
Long-term studies on children with PSGN have revealed few chronic sequelae Long-term studies show higher mortality rates in elderly patients Patients may be predisposed to crescent formation

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