Acute Post-Streptococcal Glomerulonephritis in Children

Introduction

Acute Post-streptococcal Glomerulonephritis in Children is a disease that affects the kidney. It occurs following an infection from a common cause of sore throat (Group A beta-hemolytic Streptococcus).

Clinical Definition of Acute Post-Streptococcal Glomerulonephritis in Children

Clinically, it is defined as kidney disease which presents with the following:

  1. Presence of Blood in the urine (Microscopic and macroscopic haematuria)
  2. Swelling of the eyes and both feet. Especially when the child wakes up in the morning.
  3. High blood pressure
  4. Reduced volume of urine (Oliguria)
  5. Presence of Group A-beta hemolytic streptococcus

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Why do You Need to Understand Acute Post-Streptococcal Glomerulonephritis in Children?

  1. Acute Post-streptococcal glomerulonephritis in children usually occurs more within the age of 5 – 12 years. The problem with this disease is that before the symptoms become very obvious as the ones listed above, it is first masked by sore throat (for about 1 to 2 weeks) and a type of skin infection called impetigo (a form of pyoderma) (for about 2 to 4 weeks).
  • So care-takers may find it difficult to identify or else they immediately take the child to the hospital. And the child may just be given antibiotics, maybe from a patent medicine dealer only for the symptoms to get worse.
  • It may as well first present as an ear infection before it finally manifests in the kidney which is the target of the Acute Post-streptococcal Glomerulonephritis in Children. So the child may as well just be treated for an ear infection without further investigations.
  • Also, in very rare cases, it may occur in children younger than 3 years, and older than 12 years. So it is good to learn about this and increase your index of suspicion.
  • This disease is very common among people living in developing countries like some countries in Africa, Asia, and South America.
  • Not every child has the ability to develop Acute Post-Streptococcal Glomerulonephritis. Only those who have the genetic ability to form antibodies against the antigens of the bacteria which causes Acute Post-Streptococcal Glomerulonephritis in Children will develop the disease. An example of this antibody which the body of such persons can develop is Anti-Streptolysin O.
  • Also, only a particular group (Strain) of the Streptococcus bacteria can cause Acute Post-Streptococcal Glomerulonephritis in Children. This strain is called the Nephritogenic strain.
  • It Occurs more in Males.

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Pathogenesis of Acute Post-Streptococcal Glomerulonephritis in Children

Disease Process of Acute Post-Streptococcal Glomerulonephritis in Children
  1. Usually, this disease occurs following a sore throat caused by a group of bacteria called Streptococcus.
  2. When the body senses the presence of these bacteria, the immediate response is to fight them off. This results in a chain of reactions in the body that ultimately leads to the production of antibodies to fight the bacteria.
  3. In the process of fighting the bacteria, the antibodies produced by the body to fight the antigens produced by the bacteria bind to form what is known as immune complexes.
  4. These immune complexes are then deposited in the cells of the kidney (the glomerular capillaries).
  5. Some of the antigens from this bacteria may also bind directly to the cells of the kidney (sub-epithelial glomerular sites) without the need to form immune complexes.
  6. As the immune complexes are being deposited in the kidney, it results in the inflammation of the cells of the kidney ultimately resulting in injury and damage to the glomerulus of the kidney. (The part of the kidney in charge of urine production; Ultrafiltration).
  7. Finally, this results in decreased perfusion of the kidney and reduced urine production (Oliguria).

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The Body’s Response to Acute Post-Streptococcal Glomerulonephritis in Children

So now, there is decreased urine production, and increased fluid retention. This means that even though the child takes in fluid, there is no way for the body to get rid of it through urine production as the kidney is under attack.

So the body goes into a series of reactions called the Renin-Angiotensin Aldosterone Pathway.

The end point of this reaction in Acute Post-Streptococcal Glomerulonephritis in Children is mainly to help the kidney to get rid of as much fluids as possible through urine as the body is over-loaded with fluid. So in this reaction, two chemicals are produced; Aldosterone and Angiotensin II. They both trigger the sympathetic nervous system to increase blood pressure and then blood flow to the kidney.

But this is more like a futile cycle, as the body on trying to protect the kidney, fights against itself. The Aldosterone which is produced in the Renin-Angiotensin-Aldosterone pathway causes reabsorption of salt (Sodium chloride) and water into the body, causing further fluid overload, and increasing blood pressure.

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Signs and Symptoms of Acute Post-Streptococcal Glomerulonephritis in Children

  1. It first presents with Sore throat (for 1 to 2 weeks) and Impetigo (Skin infection) for 2 to 4 weeks.
  2. Bloody urine and swelling of the face and legs are very common
  3. The color of the urine is like that of coca-cola (Reddish-brown)
  4. Complete inability to make urine or decreased volume of urine (Less than 0.5-1ml/Kg/hr)
  5. Headaches due to high blood pressure

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Other Uncommon Symptoms of Acute Post-Streptococcal Glomerulonephritis in Children

  1. Breathlessness due to increased presence of fluids in the lungs (Acute Pulmonary Oedema).
  2. Brain dysfunction due to high blood pressure (Hypertensive encephalopathy).
  3. Acute renal failure
  4. Nephrotic syndrome (Presence of protein in the urine)

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Further Studies:

Laboratory Investigations

1. Urinalysis/Urine Investigations

Dip-Stick Urinalysis will present with:
  • Mild proteinuria
  • Presence of red blood cells
Urine Microscopy will present
  • Dysmorphic red cells present
  • Presence of Red cell casts
  • Presence of Neutrophils
  • Presence of hyaline and granular casts

2. Serum Electrolyte Urea and Creatinine (SeUCr)

  • Elevated urea and creatinine
  • Hyperkalaemia
  • Metabolic Acidosis in patients with Acute Kidney Injury

3. Haematology

  • Anaemia due to haemodilution

4. Chest X-ray

  • May show heart enlargement and pulmonary congestion

5. Serology

  • Anti-Streptolysin O titer elevated within 3-5 weeks after the streptococcal infection and decreased Serum C3 Levels.

6. Renal Biopsy May Be Indicated Under the Following Conditions:

  1. When it occurs with fever, joint pains, rashes, and heart disease
  2. When there is normal Anti-Streptolysin O titre and C3 levels
  3. Mixed picture of Acute Post-Streptococcal Glomerulonephritis and Nephrotic Syndrome.
  4. Delayed cased of resolution
  5. Oliguria, Hypertension, or Azotemia beyond 2 weeks, Gross haematuria beyond 3-4 weeks, Low C3 levels past 6-8 weeks, Microscopic hematuria/proteinuria beyond 6-12 months.

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Treatment of Acute Post-Streptococcal Glomerulonephritis in Children

General Management of Acute Post-Streptococcal Glomerulonephritis in Children

  1. Maintain adequate level of fluid
  2. Restrict Sodium (salt) intake in children with body swelling and high blood pressure
  3. Restrict Potassium intake in Children with low urine output until it resolves
  4. Bed rest if high blood pressure, body swelling and heart failure is present.

Medication Guideline for Managing Acute Post-Streptococcal Glomerulonephritis in Children

  1. Use Antibiotics to treat the Streptococcal Infection
  2. Treat the Body Swelling using appropriate drugs
  3. Treat the hypertension

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Other Diseases that Presents Like Acute Post-Streptococcal Glomerulonephritis in Children and their Differences from APGN

1. Acute Interstitial Nephritis (Differences include):

  • History of Antibiotics use or analgesic use
  • Presence of fever, flank pain, and increased eosinophils in urine

2. Shunt Nephritis: Differences:

  • Previous insertion of shunts in the patient
  • Presence of protein in urine
  • Presence of Fever
  • Presence of Endurance Fatigue (Increased tiredness from mild physical activities)
  • Presence of Osler’s nodes (Immunologic phenomena)

4. Immunoglobulin-A Nephropathy: Differences

  • Previous history of Acute Renal Failure
  • Flank/Abdominal Pain
  • Compromised Immunity

5. Haemolytic Uraemic Syndrome: Difference

The child is usually less than 4 years old

Presence of thrombocytopenia

Presence of Micro-angiopathic haemolytic Anemia

Presence of Jaundice

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Prognosis

Most cases of Acute Post-Streptococcal Glomerulonephritis in Children resolves within the 1st week.

Almost everyone who suffers from this completely recovers no matter how bad the symptoms may be.

Identifying and treating the disease on time increases the chances of a good prognosis.

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Dr. Lee
Medical Student, Blogger, I.C.T Geek.

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