Glomerulonephritis Description/Etiology:

Glomerulonephritis is an inflammation of the glomerulus. There are two types of glomerulonephritis: Acute: This might occur up to 10-21 days following a respiratory tract streptococcal bacterial infection or from a skin infection as a result of antigen/antibody groups trapped in the tubules causing edema that decreases filtering and thus causes urine to be retained. Chronic: An abnormal immune system, bacterial or viral infection, disease or toxin causes progressive dysfunction of the glomerulus over the years and decline of renal function Most causes of acute GN are infectious In children, acute disease is most often a response to a group A betahemolytic streptococcal infection of the skin or pharynx (acute postinfectious glomerulonephritis or APIGN) Highest incidence in children 2-6 years of age More common in boys PATHOPHYSIOLOGY: APIGN: Acute poststreptococcal glomerulonephritis results from entrapment and collection of antigen-antibody complexes in the glomerular capillary membranes after infection with group A hemolytic streptococci. The antigens stimulate the formation of antibodies. Circulating antigen-antibody complexes become lodged in the glomerular capillaries. Glomerular injury occurs when complexes initiate the release of immunologic substances that break down cells and increase membrane permeability allowing RBC and red cell casts to be excreted

 Sodium and water are retained leading to edema The severity of glomerular damage and renal insufficiency depends on the size, number, location, duration of exposure, and type of antigen-antibody complexes. Oliguric phase initially seen in glomerulonephritis followed by a diuretic phase. Most individuals with acute glomerulonephritis (AGN) improve dramatically within weeks and recover completely within 1-2 yr Renal damage continues to progress for patients with chronic glomerulonephritis (CGN). CGN is one of the most common causes of chronic renal failure (CRF) CLINICAL MANIFESTATIONS (adults and children the same): Many children are asymptomatic. Abrupt onset of symptoms Flank or mid-abdominal pain Irritability Malaise Fever (AGN) Dyspnea Orthopnea and dyspnea Moist crackles on auscultation Distended neck veins Periorbital edema

 Facial edema that is worse in the morning but then spreads to extremities and abdomen with progression of the day Mild to severe hypertension Decreased glomerular filtration rate leading to decreased urine output

Changes in the level of consciousness Anorexia/nausea Headache Back pain Pruritus (CGN) Oliguria (especially with CGN) Uremia (CGN) Azotemia Acidosis (CGN)

LABORATORY/DIAGNOSTIC TESTS Elevated BUN and serum Creatinine

Antistreptolysin-O (ASO) titer: positive indicating the presence of strep antibodies from a recent strep respiratory infection Erythrocyte sedimentation rate (ESR) (elevated indicating active inflammatory response) White blood cell count: elevated indicating inflammation and presence of active strep infection

 Urinalysis reveals: proteinuria, hematuria, cell debris (red cells and casts), increased urine specific gravity, urine has a smoky or tea color to it Electrolyte abnormalities: hyperkalemia, hypoalbuminemia, and hyperphosphatemia Antihyaluronidase (AHase), antideoxyribonuclease B (ADNase-B), and streptozyme antibodies may be present.

Serum complement (C3) Decreased initially; increases as recovery takes place; returns to normal at 8 to 10 weeks post glomerulonephritis

X-ray of kidney, ureter, bladder (KUB), and renal ultrasound (to detect structural abnormalities, kidneys may be enlarged with AGN but shrunken and atrophied in CGN) Renal biopsy (to confirm or rule out diagnosis) Chest x-ray may show cardiac enlargement, pulmonary congestion, or pleural effusion during the edematous phase of acute disease. MEDICAL MANAGEMENT: Management consists of general supportive measures and early recognition and treatment of complications.

Patients who have normal blood pressure and a satisfactory urine output can often be treated at home.

Patients with substantial edema, hypertension, gross hematuria, or significant oliguria are hospitalized because of the unpredictability of complications.

 Dietary restrictions depend on the stage and severity of the disease, especially the extent of edema. Moderate sodium restriction and even fluid restriction may be instituted for patients with hypertension and edema. Foods with substantial amounts of potassium are generally restricted during the period of oliguria.

Antibiotic therapy is indicated only for those children with evidence of persistent streptococcal infections.

Diuretics such as furosemide (Lasix) to reduce extracellular fluid overload

Antihypertensive such as hydralazine.

Corticosteroids such a prednisone to reduce the inflammatory response.

Severe hypertension is children is a medical emergency and can cause seizures and encephalopathy

Dialysis if the patient goes into uremia or acute renal failure.

NURSING MANAGEMENT: Careful assessment of the disease status, with regular monitoring of vital signs (including frequent measurement of blood pressure), fluid balance, and behavior

 Evaluate and record the volume and character of urine, and weigh the patient daily.

Observe for signs of dehydration in children with restricted fluid intake, especially those who are not severely edematous or those who have lost weight.

For most patients a regular diet is allowed, but it should contain no added salt. Foods high in sodium and salted treats are eliminated, and parents/patients and friends are advised not to bring snacks such as potato chips or pretzels.

Fluid restriction, if prescribed, is more difficult, and the amount permitted should be evenly divided throughout the waking hours.

Assess respiratory system for lung sounds, difficulty breathing, crackles in the lungs suggesting fluid overload Assess cardiovascular status, heart rate, heart sounds, presence of S3 suggesting fluid overload.

Assess extremities for edema.

Monitor serum electrolytes, BUN, and creatinine.

If severe hypertension is present monitor the patients neurological status closely and implement seizure precautions if necessary.

Patient and Family Teaching Educate the patient/caregivers about appropriate dietary management/restrictions.

Provide parent/patient education and support in preparation for discharge and home care; include education in home management and the need for follow-up care and health supervision.

Stress to the patient the need for regular blood pressure, urine protein, and renal function assessments during the convalescent months to detect recurrence. Teach the family about administration and side effects of antibiotics, corticosteroids, diuretics and antihypertensive medications.

Advise the patient with a history of chronic upper respiratory tract infections to report immediately signs and symptoms of infection (such as fever or sore throat).

Encourage a pregnant woman with a history of the disorder to have frequent medical evaluations because pregnancy further stresses the kidneys and increases the risk of chronic renal failure.