ACUTE

GLOMERULONEPHRITIS
INTRODUCTION
 ACUTE GLOMERULONEPHRITIS
 is active inflammation in the glomeruli.

 is characterized by the sudden appearance of hematuria,

proteinuria, red blood cell casts in the urine, edema,
and hypertension with or without oliguria.

 2 forms:
 Post infectious glomerulonephritis- typically occurs about 21
days after a respiratory or skin infection with Streptococcus.
 Infectious glomerulonephritis- Infectious glomerulonephritis
occurs during or within a few days of streptococcal infection.
 Epidemiology: it primarily occurs in developing countries. Of
the estimated 470,000 new annual cases of AGN worldwide, 97
percent occur in developing countries, with an annual
incidence that ranges from 9.5 to 28.5 per 100,000 individuals.

 Risk: Males are twice as likely to have the condition as females,

and although glomerulonephritis can appear at any age, 90%
of cases occur in those under 40 years. The disease most often
develops in boys between 2 and 14 years.
 Incidence and Prevalence: There has been a significant decline
in the incidence of acute glomerulonephritis in developed
countries such as the US, and cases are reported only
sporadically. The declining incidence rates are probably related
to improved nutritional status in these countries and more
liberal use of antibiotics. Developing countries, such as those in
Africa and the Caribbean, appear to have a higher potential for
development of streptococcal infections, and the incidence of
acute glomerulonephritis is proportionally higher in these
areas.
CASE PRESENTATION
• Kid Nee Bowman, a 9 yr old male was brought to the hospital for
periorbital edema, tea colored urine and hematuria. Five days prior to
admission, he had intermittent fever ranging from 38-39 degrees Celsius

• Subjective data: N/A

• Objective data:
– Vital Signs: T – 36.6 degrees Celsius, PR – 88, RR – 30cpm, BP –
140/120
– Skin is dry and warm to touch, periorbital edema and tea colored urine
was noted.
– Serum Creatinine : 0.71 ( normal values: 0.6-1.2)
– CBC
o Hgb: 124g/dL (normal values: 140-180mg/dL)
o RBC: 5.25 x 1012 /L (normal values: 4.0-5.0 x 1012 /L)
o Hct: 0.40% (normal values: 0.42-0.52%)
o WBC: 8.0 x 10g/L (normal values: 5-10g/L)
Lymphocytes: 0.38% (normal values: 0.20-0.40%)
Segmenters: 0.58% (normal values: 0.40-0.60)
Platelets: 250x 10/L (normal values: 150-350 x 10/L
• Objective data (cont.) :
– Urinalysis:
o Color: Yellow
o Transparency: Turbid
o pH 6.0 (normal values: 5.5-6.5)
o Sugar: (-)
o Albumin: (+)
o Specific gravity: 1.025 (normal values: 1.003-1.035)
o Pus cells: 35-40
o RBC: too many to count (normal values: <2)
o Epithelial cells: moderate
o Bacteria: moderate
– KUB ultrasound: No evidence of calculi, normal gastrointestinal
pattern
– Cholesterol: 140.3 mol/L (Normal values: 140-230 mol/L)
• Assessment: Acute Glomerulonephritis

• Plan:
– Hydralazine 5mg IV q6hrs PRN for BP 130/90
– Furosemide 20mg SIVP OD; refer if BP is less than 90/60mmHg
– Co-Amoxiclav IV
– Diet: low salt, low fat diet

• The patient was discharged on August 17, 2010.

FAMILY HISTORY
RELEVANT ANATOMY AND
PHYSIOLOGY
Relevant Anatomy and Physiology
• The Urinary System
• Functions:
• Excretion
• Regulation of blood volume and pressure
• Regulation of the concentration of solutes in the blood
• Regulation of extracellular fluid pH
• Vitamin D synthesis
Relevant Anatomy and Physiology
• The Kidneys
• Functions:
• Excretion
• Regulation of blood
volume and pressure
• Regulation of the
concentration of solutes
in the blood
• Regulation of
extracellular fluid pH
• Vitamin D synthesis
Relevant Anatomy and Physiology
• The Kidneys
• lie retroperitoneally
• Right kidney lies slightly
lower than the left
Relevant Anatomy and Physiology
• The Kidneys
• Hilum
• Renal artery and vein,
lymphatics, nerve supply
and the ureters
Relevant Anatomy and Physiology
• The Kidneys
• Hilum
• Renal artery and vein,
lymphatics, nerve supply
and the ureters
• Longitudinal Section
• Outer cortex
• Inner medulla
Relevant Anatomy and Physiology
• The Kidneys
• Medulla
• Renal pyramids
• Terminate in the papilla
• Renal pelvis
• Major calyces
• Minor calyces
Relevant Anatomy and Physiology
• The Kidneys
• excrete most of the
waste products of
metabolism
• controlling water and
electrolyte balance
• maintaining acid-base
balance in the blood.
Relevant Anatomy and Physiology
• The Kidneys
• waste products leave the
kidneys as urine.
• ureter
Relevant Anatomy and Physiology
• Renal Blood Flow
• Renal artery enters the
hilum
• Interlobar
• Arcuate
• Interlobular (radial)
• Afferent arteriole
• Glomerular capillaries
• Efferent arteriole
• Peritubular capillaries
Relevant Anatomy and Physiology
• Renal Blood Flow
• Glomerular and
peritubular capillaries
• arranged in series and
separated by the efferent
arterioles
• High hydrostatic pressure
in glomerular capillaries=
rapid fluid filtration
• lower hydrostatic
pressure in peritubular
capillaries = rapid fluid
reabsorption
Relevant Anatomy and Physiology
• Renal Blood Flow
• Peritubular capillaries
• Empty into the vessels of
the venous system
• Interlobular vein
• Arcuate vein
• Interlobar vein
• Renal vein
Relevant Anatomy and Physiology
• Nephrons
• about 1 million
nephrons for each
kidney
• cannot regenerate
Relevant Anatomy and Physiology
• Nephrons
• Glomerulus
• network of branching
and anastomosing
glomerular capillaries
• high hydrostatic pressure
• covered by epithelial
cells
• Encased in Bowman’s
capsule
Relevant Anatomy and Physiology
• Nephrons
• Glomerulus
• Fluid filtered flows into:
• Bowman’s capsule
• Proximal tubule (in the
cortex)
• Loop of Henle
• Descending limb
• Ascending limb
• Macula densa
• Contain golgi
apparatus
• Secretion towards
arterioles
Relevant Anatomy and Physiology
• Nephrons
• Glomerulus
• Beyond macula densa
fluid flows through:
• Distal tubule
• Connecting tubule
• Cortical colleting tubule
• Cortical collecting duct
• Medullary collecting
duct
• Collecting ducts
• Renal papillae
Relevant Anatomy and Physiology
• Regional Differences in
Nephron Structure
• Cortical nephron
• short loops of Henle
• penetrate only a short
distance into the medulla
• tubular system is
surrounded by an
extensive network of
peritubular capillaries
Relevant Anatomy and Physiology
• Regional Differences in
Nephron Structure
• Juxtamedullary nephron
• long loops of Henle
• dip deeply into the
medulla
• long efferent arterioles
extend from the
glomeruli down into the
outer medulla
• Divide into vasa recta
• plays an essential role
in the formation of
concentrated urine.
Relevant Anatomy and Physiology
• Micturition
• process by which the
urinary bladder empties
when it becomes filled
• Two steps:
• fills progressively until
the tension in its walls
rises above a threshold
level
• Micturition reflex ->
empties bladder
• OR conscious desire to
urinate.
Relevant Anatomy and Physiology
• Renin – Angiotensin –
Aldosterone System
• help regulate
aldosterone secretion
• blood pressure or Na
concentration in the
blood
Relevant Anatomy and Physiology
• Renin – Angiotensin –
Aldosterone System
• Renin – from
juxtaglomerular apparatus
is released
• Acts on angioteninsinogen
from the liver
• Angiotensin I
• Converted to Angiotensin
II by Angiotensin
converting enzyme (ACE)
from endothelial cells
Relevant Anatomy and Physiology
• Renin – Angiotensin –
Aldosterone System
• Angiotensin II
• Acts on adrenal cortex
• Aldosterone is released
• Aldosterone
• Increase in Na and Cl
reabsorption from the
nephrons
• Increases the rate of active
transport of Na in the
distal tubules and
collecting ducts
• Decreased urine output
PATHOPHYSIOLOGY
 Precipitating factors:
Pre-disposing 1. Previous exposure to infectious
factors: Streptococcus infection disease
- primary complex
1. Age (9 y/o) -cough,colds, fever
2. Gender (male) - scabies
1. Diet
- High Na intake
Pus cells: 35-40
Turbid urine
Bacteria: moderate
Epithelial cells: moderate
5 days prior
to admission
(38-39oC)

Tea-colored
urine
RBC: too
many to + protein in
count urine
Hb: 124 g/dL (140-180)
Periorbital edema

BP: 140/120
TREATMENT AND
MANAGEMENT
Acute glomerulonephritis is usually self-limiting, so management is aimed
at treating symptoms, preserving kidney function and treating
complications promptly. Pharmacologic treatment depends on a case-
to-case basis. If there is residual streptococcal infection, then penicillin
is the drug of choice; however, other antibiotics can also be given. Loop
diuretics and anti-hypertensives are used to control hypertension.
Sodium is restricted, as is fluid intake because of fluidvolume excess.
Carbohydrates are given liberally to provide energy and to reduce catabolism
of proteins. As for proteins, there are two schools of thought: dietary
restriction or increased intake. Dietary restriction is merited only when
there is nitrogen retention (elevated BUN) and/or renal insufficiency.
However, due to albuminuria, the client loses more proteins than can be
replaced. Hence, most diets would include foods high in albumin and
other complete proteins, such as egg whites and dairy products.
>Intake and output are measured carefully and recorded.

>Patients daily weight is also recorded using the same scale at the same time of
the day as previous weighing sessions.

>Assess also for signs of increased ICP, such as headaches orblurring of vision.

>Client is also advised to report immediately should any signor symptom of renal
failure occur (fatigue, nauseas,vomiting, diminishing urine output).

>Maintain dietary and fluid restrictions to avoid worsening edema and

hypertension.

>Stress the importance of follow-up check-ups to monitor BP,urinalysis, blood

chemistry and CBC, to determine whetherthere is progress in the management of
the disease.

>Educate client and significant others on properadministration of medications,

especially those taken orally;include adverse effects, dosage, time, frequency, and
thedesired actions of the medications taken and theprecautions to be followed.
Inpatient and Outpatient Care
Inpatient care may be necessary, based on the type and/or etiology of acute
glomerulonephritis (eg, shunt nephritis), the extent of renal involvement, or
the existence of signs and symptoms indicative of potentially serious
complications (eg, pulmonary edema, severe hypertension, encephalopathy).
A follow-up evaluation by a nephrologist is essential for all patients who do
not meet admission criteria. Goals include the following:

>Ensure appropriate evaluation of the etiology

>Reassess and address the course the illness takes in its progression
>Provide any intervention or treatment indicated based on the specific
etiology and
the course it follows in that specific patient
>Outpatient care should include the following:
Urinalysis at 2, 4, and 6 weeks and at 4, 6, and 12 months
Cessation of follow-up care when urinalysis is normal
Blood pressure monitoring during each visit
Serum creatinine level monitoring at 2, 6, and 12 months
Serum complement usually normal by 6 weeks
DIFFERENTIAL DIAGNOSIS
Characteristics/ Acute Renal Poststreptococcal
AGN
Tests Failure Glomerulonephritis

Creatinine Levels •Increased •Increased •Increased

Urinalysis •Tea colored urine •Reddish brown or •Proteinuria

•Proteinuria cola-colored urine
•Hematuria •Proteinuria

Swelling/Edema •Present •Present •Present

Anemia •Present •Present •Absent