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Acute Nephritic Syndrome      

Title               

Ñ    Acute Nephritic Syndrome

Definition

A syndrome characterised by:

Pathologically

Ñ    Diffuse inflammatory changes in the glomeruli

Clinically

Ñ    Haematuria (macroscopic or microscopic):

With red cell casts seen on microscopy

Ñ    Proteinuria

Ñ    Hypertension

Ñ    Oedema

Ñ    Oliguria

Ñ    Uraemia

Pathogenesis

Causes

Post-Infectious

Ñ    Post-streptococcal:

·          Following infection with Lancefield group A b haemolytic streptococcus

This may be:

·          Pharyngitis

·          Otitis media

·          Cellulitis

·          Impetigo

Ñ    Bacterial endocarditis

Ñ    Shunt nephritis:

Ventriculo-atrial shunts

Ñ    Viral infections:

CMV

Hepatitis virus

Epstein-Barr virus

Ñ    Parasitic infections:

Plasmodium falciparum

Systemic factors

LMS

Ñ    SLE (systemic lupus erythematosus)

Ñ    Polyarteritis nodosa

Ñ    Henoch-Schonlein purpura

RS

Ñ    Wegener’s granulomatosis

Ñ    Goodpasture’s syndrome

KUS

Ñ    Rapidly progressive glomerulonephritis

Pathological Process

Ñ    Immune complex deposition in the basement membrane

Ñ    Thickening of the glomerular basement membrane

Ñ    Infiltration by neutrophils and monocytes

Ñ    Proliferation of endothelial, mesangial and epithelial cells

Resulting in:

Ñ    Proteinuria

Ñ    Haematuria

Ñ    Active urine sediment with red blood cells and red blood cell casts

Ñ    Reduction in GFR

Ñ    Avid distal nephron salt and water retention

Clinical Features

History

Latent Period

Between infection and onset of symptoms:

Ñ    1-3 weeks

IS

Ñ    Oedema

KUS

Ñ    Haematuria

Ñ    Oliguria

Examination

CVS

Ñ    Hypertension

IS

Ñ    Oedema:

Periorbital

Sacral

Pedal

KUS

Ñ    Haematuria

Ñ    Proteinuria

Ñ    Uraemia

Complications

CVS

Ñ    Pulmonary oedema

KUS

Ñ    Severe uraemia

CNS

Ñ    Hypertensive encephalopathy

Investigations

Fluids

Urine

Haematology

Ñ    Red cells +

Ñ    Red cell casts +

Biochemistry

Ñ    Urine proteins +

Blood

Biochemistry

Ñ    Blood urea:

Elevated

Ñ    Creatinine:

Increased

Immunology

Ñ    Antisteptolysin-O-titre (ASOT):

Elevated

Ñ    C₃, C ₄ levels:

Reduced

Imaging

Ultrasound scan

Ñ    Normal or slightly enlarged kidneys

Physiological studies

Creatinine clearance

Ñ    Reduced

Tissue Diagnosis

Renal biopsy

Ñ    Glomerulonephritis

Management

Control

Drugs

Ñ    Antihypertensives

Ñ    Diuretics

Ñ    Penicillin:

Post-streptococcal glomerulonephritis

Lifestyle Adjustments

Ñ    Low salt diet

Ñ    Low protein diet:

If uraemia severe

Support

Equipment

Ñ    Peritoneal or haemodialysis:

Severe uraemia

Prevention

Drugs

Ñ    Prophylactic penicillin:

Outbreak in a closed community

Prognosis

Ñ    Children:

Prognosis excellent

Ñ    Adults:

A small number may develop hypertension or renal impairment later in life

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