Acute post .

streptococcal GN

APSGN

Def : acute nephritic syndrome preceded by infection with nephritogenic strains of

group A B hemolytic
Streptococci .
[ serotype 4 , 12 ---------> throat infection & serotype 49
---------> skin infection ]

Pathogenesis :
-

Strept . infection --------------> antibody formation .

Ag + Ab + complement ( C3 ) --------> immune complex deposition in
glomerular BM leading to :
Damage of glomerular endothelium ----------> escape of RBCs & proteins in
urine ( Hematuria ).
Proliferation of endoth , epith , mesangial cells ------> glomerular capillary
permeability ---> GFR
- GFR --------> Oliguria
-------> Fluid retention , hypervolemia
-------> Odema .
--------> renal ischemia -------> + Renin angiotensin system
-------> HPN .

Pathology :
-

diffuse proliferative GN
LM : proliferation of endoth , epith , mesangial cells
capillaries .
Immunofluorescent : granular deposit of IgG , C3 .
EM : subepithelial deposits humps .

--------> occlusion of

Clinical picture

Incidence : age -------> 5 12 years .

[ rare before 3 years ] .
History of skin or throat infection : 1 3 w ago followed by :
Hematuria
: painless smoky urine ( cola coloured urine ).
Oliguria
: due to GFR
( < 400 ml / m / day
).
Odema
: mild , localized start in the morning around eyes & at
the end of the day .
Hypertension
: due to salt & water retention ( may lead to HPN .
encephalopathy , HF ) .

Complication
Hypertensive Heart failure
:
tachycardia - tachypnea - enlarged tender
liver .
Hypertensive encephalopathy :
Headache - vomiting - convulsion .
Renal impairement
:
( transient ) , but may progress to RPGN ------->
acidosis .

Investigation

Urine analysis
- Volume : oliguria
( < 400 ml / m / day ) .
- Aspect : smoky urine ( cola coloured urine ) .
- Proteins : proteinuria ( mild ) .
- Sp . gravity :

- Microscopic Examination : RBCs Cast ( pathognomonic ) .

Blood investigation
- Plasma proteins
: Normal .
- Plasma lipids
: Normal .
C . B .C
:
anemia .
- Serum electrolyte : K
, dilutional hyponatremia .
- Serum complement : C3 .
- + Evidence of recent strept . infection . [ ASOT - Anti DNAase throat swab ] .
Renal function tests : may be impaired
[ urea , creatinine ] .
Renal imaging
: Abd U/S may show swelling of kidneys .
Renal biopsy
:
not required , only indicated in atypical presentation
: - Associated NS ( Nephritic Nephrosis )
- Normal C3 .
- Persistent Hematuria > 3 months .
- ARF .

D .D :
-

Other causes of Hematuria .

Other causes of Odema
[ Nephrotic syndrome ]

Treatment
Prevention : early ttt of strept . infection not risk of APSGN .
TTT
Monitoring : dailt wt . - urine output / 24 h - Bl . pressure - Odema .
Diet
- Salt restriction .
- Fluid restriction .
[ fluid intake = urine ouput + insensible water
loss 400 ml / m / d
- CHO , proteins , fats .
TTT of odema
- Thiazide
( chlorothiazide ) 1 2 mg/kg/day .
- Loop diuretic
(
frusemide
) 1 2 mg/kg/day .

TTT of strept . infection : penicillin for 10 days .

TTT of HPN
: Antihypertensive drugs [ captopril hydralazine - Na nitroprusside ]
TTT of complication
- HF
--------> diuretics , digitalis .
- ARF --------> dialysis .