ACUTE GLOMERULONEPHRITIS

Glomerulonephritis is a type of kidney disease that involves the glomeruli. The glomeruli are very small, important structures in the kidneys that supply blood flow to the small units in the kidneys that filter urine, called the nephrons. During glomerulonephritis, the glomeruli become inflamed and impair the kidney's ability to filter urine. It may present with isolated hematuria and/or proteinuria(blood or protein in the urine); or as a nephrotic syndrome, a nephritic syndrome, acute renal failure, or chronic renal failure. They are categorized into several different pathological patterns, which are broadly grouped into non-proliferative or proliferative types. Diagnosing the pattern of GN is important because the outcome and treatment differs in different types. Primary causes are intrinsic to the kidney. Secondary causes are associated with certain infections (bacterial, viral or parasitic pathogens), drugs, systemic disorders (SLE, vasculitis), or diabetes.

CAUSES
Glomerulonephritis is caused by several different disease states, including the following:

Systemic immune disease such as systemic lupus erythematosus (SLE, or lupus) Other systemic diseases may include: o Polyarteritis nodosa group. An inflammatory disease of the arteries. o Wegener vasculitis. A progressive disease that leads to widespread inflammation of all of the organs in the body. o Henoch-Schnlein purpura. A disease usually seen in children that is associated with purpura (small or large purple lesions on the skin and internally on the organs) and involves multiple organ systems. A form of inherited glomerulonephritis called Alport syndrome, which affects both men and women; men are more likely to have kidney problems. Treatment focuses on preventing and treating high blood pressure and preventing kidney damage. In children, a common cause of glomerulonephritis is from a streptococcal infection, such as strep throat or upper respiratory infection. Glomerulonephritis usually occurs more than one week after an infection. This is often referred to as acute poststreptococcal glomerulonephritis, or APSGN.

SIGNS AND SYMPTOMS

The following are the most common symptoms of glomerulonephritis. However, each child may experience symptoms differently. Symptoms may include:

Dark brown-colored urine (from blood and protein) Sore throat Diminished urine output Fatigue Lethargy Increased breathing effort Headache High blood pressure Seizures (may occur as a result of high blood pressure) Rash, especially over the buttocks and legs Weight loss Joint pain Pale skin color Fluid accumulation in the tissues (edema)

The symptoms of glomerulonephritis may resemble other conditions and medical problems. Always consult your child's doctor for a diagnosis.

DIAGNOSIS
In addition to a thorough physical examination and complete medical history, your child's physician may recommend the following diagnostic tests:

Throat culture Urine tests Blood tests Electrocardiogram (ECG or EKG). A test that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias or dysrhythmias), and detects heart muscle damage. Renal ultrasound (also called sonography). A noninvasive test in which a transducer is passed over the kidney producing sound waves which bounce off of the kidney, transmitting a picture of the organ on a video screen. The test is used to determine the size and shape of the kidney and to detect a mass, kidney stone, cyst, or other obstruction or abnormalities.

Chest X-ray. A diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. Renal biopsy. A procedure during which a small sample of tissue is taken from the kidney through a needle. The tissue is sent for special testing to determine the specific disease.

TREATMENT
Specific treatment for glomerulonephritis will be determined by your child's doctor based on:

Your child's age, overall health, and medical history The extent of the disease Your child's tolerance for specific medications, procedures, or therapies Expectations for the course of the disease Your opinion or preference

If glomerulonephritis is caused by a streptococcal infection, then treatment will be focused on curing the infection and treating the symptoms associated with the infection. Treatment will depend on the underlying cause. Therefore, treatments focus on slowing the progression of the disease preventing complications. Treatment for glomerulonephritis may include:

Fluid restriction Decreased protein diet Decreased salt and potassium diet Medication, such as: o Diuretics o Blood pressure medications o Phosphate binders. Medications to decrease the amount of the mineral phosphorus in the blood. o Immunosuppressive agents Dialysis. A medical treatment to remove wastes and additional fluid from the blood after the kidneys have stopped functioning. Dialysis may be required for short-term or long-term therapy.

If glomerulonephritis does not resolve, long-term kidney failure may need to be addressed.

MEDICAL MANAGEMENT
General management begins with a decision to admit the child with acute glomerulonephritis to the hospital or merely have him or her undergo frequent outpatient examinations. Hospitalization is indicated if the child has significant hypertension or a combination of oliguria, generalized edema, and elevation of serum creatinine or potassium. Severe hypertension Severe hypertension, or that associated with signs of cerebral dysfunction, demands immediate attention. Debate exists regarding the agent that is most effective in patients with severe hypertension. Three drugs are commonly cited as having a high benefit-to-risk ratio: labetalol (0.5-2 mg/kg/h intravenously [IV]), diazoxide, and nitroprusside (0.5-2 mcg/kg/min IV; in patients with severe hypertension that is refractory to the previous agents). In combination with any of these agents, the simultaneous IV administration of furosemide at doses of 2 mg/kg may be merited. Diazoxide use for blood pressure (BP) control is limited because, once administered, no further control of pressure is possible, unlike labetalol or nitroprusside. Severe hypertension without encephalopathy can be treated in the manner described above or, more commonly, by administration of vasodilator drugs, such as hydralazine or nifedipine. The doses of these drugs can be administered either by injection or by mouth and can be repeated every 10-20 minutes until a suitable response is obtained. For most children, the need for more than 2-3 doses is unusual. Mild-to-moderate hypertension Mild-to-moderate hypertension does not warrant emergency management and is treated most effectively with bedrest, fluid restriction, and less-frequent doses of the medications mentioned above. The use of loop diuretics, such as furosemide (1-3 mg/kg/d oral [PO], administered 1-2 times daily), may hasten resolution of the hypertension. For patients resistant to treatment, either hydralazine or nifedipine is indicated. Angiotensin-converting enzyme (ACE) inhibitors are effective, although these agents have the potential to produce hyperkalemia and usually are not first-line drugs in acute glomerulonephritis. Edema and circulatory congestion are usually not sufficiently marked to produce more than minimal discomfort. Restriction of fluids to those amounts needed to replace insensible losses is the best treatment for edema and circulatory congestion.

 Loop diuretics (furosemide) administered PO have been reported to reduce the length of hospitalization in children who are edematous. If congestion is marked, administer furosemide parenterally (2 mg/kg). Phlebotomy, rotating tourniquets, dialysis, or digitalization is rarely necessary. Anuria or oliguria Anuria or severe and persistent oliguria may occur in 3-6% of children with acute glomerulonephritis and may necessitate hospitalization. Fortunately, both of these conditions are usually transient. Because they may be ototoxic, avoid large doses of furosemide in children with symptoms of anuria or severe and persistent oliguria. In addition, osmotic diuretics, such as mannitol, are contraindicated, as they might increase vascular volume.

NURSING INTERVENTION
1. 2. 3. 4. Provide bed rest during acute phase. Perform passive ROM exercises for the patient on bed rest. Allow patient to resume normal activities gradually as symptoms subside. Consult the dietician about a diet high in calories and low in protein, sodium, potassium, and fluids. 5. Protect the debilitated patient against secondary infection by providing good nutrition and hygienic technique and preventing contact with infected people. 6. Check the patients vital signs and electrolyte value. 7. Monitor intake and out put and weight daily. 8. Report peripheral edema or the formation of ascites. 9. Explain to the patient taking diuretics that he may experience orthostatic hypotension and dizziness when he changes positions quickly. 10. Provide emotional support for the patient and his family. 11. If the patient is for dialysis, explain the procedure fully.