1. Prof. Rai Muhammad Asghar Head of Paediatric Department RMC Rawalpindi

2. Acute Post streptococcal Glomerulonephritis

3. Sudden onset of
Gross hematuria
Edema
Hypertension
Renal insufficiency

4. Cause of AGN Post infectious (Gp A B sterp) Vasculitis HS purpura SLE
Microscopic polyarteritis
Polyarteritis nodosa
IgA nephropathy
Antiglomerular basement membrane disease

5. Post streptococcal Glomerulonephritis
Triad of
Acute nephritic syndrome
Evidence of recent strep infection
Low C3 level

6. ETIOLOGY and EPIDEMIOLOGY
Infection of the throat or skin by nephrogenic strains of group A beta – hemolytic sterptococci Commonly follows streptococcal pharyngitis during cold weather months and sterptococcal skin infections or pyoderma during warm weather

7. Pharyngitis
Pyoderma
Strep type
Gp A (12)
Gp A (49)
Climate
Temperature , Cold
Hot, tropical
Season
Wniter & spring
Summer & fall
Incubation period
1-2 wks
3-6 wks
Sex incidence
B:G
2:1
Equal

8. PATHOLOGY Light microscopy: Enlarged and bloodless glomeruli
Diffuse mesangial proliferation with increase in mesangial matrix
Polymorphonuclear leukocytes
Crescent farmation and interstitial inflammation

9. Immunofluorescene microscopy
Lumpy – Bumpy deposits of immunoglobulin and complement on GBM and in the mesangium
Electron Microscopy
Electron – dense deposits, or humps are observed on epithelial of the GBM

10. PATHOGENESIS Exact mechanism not known
Morphological studies and depression in the serum complement (C3) level strongly suggest immune mediated illness

11. CLINICAL MANIFESTATIONS
Age 5-15 year
Incubation period: 1-2 weeks after pharyngitis
3-6 weeks after pyoderma
Hematuria either asymptomatic microscopic with normal renal function or
Gross hematuria (cola colored)
with acute renal failure
Oliguria
Edema
Hypertension
Hypertensive encephalopathy

12. Edema results from salt and water retention and nephrotic syndrome may develop in < 5%
Malaise, lethargy, abdominal or flank pain and fever are non specific features
Acute subglottic edema and airway compromise
Acute phase resolve within 6-8 weeks,
urinary protein excretion and hypertension normalize by 4-6 weeks
persistent microscopic hematuria may persist for years

13. INVESTIGATIONS Urine R/E Renal function Test Serum electrolytes CXR
Red blood cells
Red blood cells cast
Proteinuria
Leukocytes
Renal function Test
Serum electrolytes
Hyponatermia and hyperkalemia
CXR

14. Evidence of streptococcal infection
Throat culture
Raised ASO titer
Streptozyme Test
Complement C3 Level
Low
Complete Blood count
Hemoglobin – Low
Total and differential count usually within normal limits
Retics – Raised
ESR- Raised

15. Indication for Renal Biopsy
Acute renal failure
Nephrotic syndrome
Absence of evidence of streptococcal infection
Normal complement level
Hematuria, Proteinuria, diminished renal function and or a low C3 level persist more than 2 months after onset

16. Differential Diagnosis
UTI
Nephrotic syndrome
CRF
Liver disorders
Cardiac disease
Malabsorption disorder

17. Differential Diagnosis
Membrano-proliferative glomerulonephritis
IgA nephropathy
Systemic lupus erythematosis
Henoch-schonlein purpura
Hemolytic Uremic Syndrome
Infective Endocarditis

18. Complication Hypertension Acute renal failure Heart failure
Hyperkalemia
Hyperphosphatemia
Hypocalcemia
Acidosis
Seizures
Uremia

19. Treatment General and Supportive Care Treatment of Complications
Bed Rest
Antibiotics (benzyl penicillin x 10 days)
Dietary Restriction
Treatment of Complications
Renal failure
Left Ventricular failure
Hypertensive

20. ARF Protein restriction Fluid & electrolyte balance Acid base balance
Control of infections
Control of seizures
Anemia

21. Heart Failure Bed Rest Prop up O2 inhalation Digitalization Diuretics
ACE inhibitors

22. Hypertensive Encephalopathy
Labetalol 0.2 – 1.0mg/kg/dose then 0.25 – 2.0mg/kg/hour
Isosorbide dinitrate (Isoket) 5µg/kg/mint
Hydralazine 0.15kg/dose
Furosemide ( 1-2mg/kg/dose 4-6 hrly)
Captopril (0.5-5mg/kg/day 8 hrly)

23. Prevention
Early systemic antibiotic therapy dose not eliminate the risk
Family members of patients with AGN should be cultured for group A beta hemolytic streptococcus and treated if culture positive

24. Prognosis Complete recovery in more than 95% cases
Infrequently, the acute phase be severe and lead to glomerular hyalinization and chronic renal insufficiency
Recurrences are extremely rare

25. Thank You