Question 1 of 10

    Acute Glomerulonephritis (Acute Glomerulonephritis Syndrome)

    Post-infectious glomerulonephritis - very high mag[1]

    Acute glomerulonephritis (AGN) is an immune-mediated inflammation and destruction of the glomeruli and peri-glomerular tissues including the basement membrane, mesangium, and the capillary endothelium.

    Acute Glomerulonephritis is related to this process: auto-immune.

    Presentation

    AGN is asymptomatic in approximately 50% of patients. In those who present with symptoms, the initial presentation is peripheral edema, low urine volume, and dark-colored urine due to hematuria.The reduction in GFR coupled with the salt and water retention in the distal tubule results in an increased intravascular volume, edema, and systemic hypertension. Edema appears as facial and periorbital swelling initially, before becoming obvious in the lower extremities. Elevated blood pressure progresses with the kidney damage. Non-specific symptoms are also common and include nausea, malaise, and dizziness.

    Fever and fatigue are the most frequent presentations of rapidly progressive glomerulonephritis. Other symptoms include nausea, anorexia, vomiting, arthralgia, and abdominal pain. Furthermore in these cases, hypertension is usually absent or mild.

    The symptoms of acute post-streptococcal glomerulonephritis include passage of coke-colored or dark brown urine, hypertension, facial puffiness and pedal edema, and proteinuria on urinalysis [11]. Occasionally, the complications of hypertension such as seizures and persistent headaches may be the only presentations of the patient.

    urogenital
    Hematuria
    • One of Cohen and Levitt's cases had no hematuria and essentially no proteinuria.[annals.org]
    • Microscopic hematuria is not the norm, but may occur in up to 25% of patients, and macroscopic hematuria is decidedly rare.[clevelandclinicmeded.com]
    • IgA glomerulonephritis IgA nephropathy; a chronic form marked by a hematuria and proteinuria and by deposits of immunoglobulin A in the mesangial areas of the renal glomeruli, with subsequent reactive hyperplasia of mesangial cells. lobular glomerulonephritis[medical-dictionary.thefreedictionary.com]
    • Urine microscopy showed hematuria and glomerular casts.[atmph.org]
    • Diagnostic Tests Urinalysis Hematuria (microscopic or gross), proteinuria, sediment, RBC casts Blood chemistry Increased blood urea nitrogen, serum creatinine, and serum lipid; decreased serum albumin Renal biopsy Obstruction of glomerular capillaries[medi-info.com]
    Oliguria
    • Glomerulonephritis, The nurse wants to ask Ask patient if it is hard to breath; if they are short of breath; Ask the patient about change in urineation pattern or color (microscopic blood causes urine to be smoky or cola color); Ask the patient about dysuria or oliguria[quizlet.com]
    • Among the signs and symptoms of acute proliferative glomerulonephritis are the following: Hematuria: Oliguria Edema Hypertension Fever, headache, malaise, anorexia, nausea.[en.wikipedia.org]
    • Acute postinfectious (poststreptococcal) diffuse proliferative glomerulonephritis is a primary glomerulonephritis, which produces nephritic syndrome (hematuria, oliguria, uremia, hypertension and mild proteinuria).[pathologyatlas.ro]
    • Symptoms PSGN Onset of symptoms occurs 1 to 6 weeks after infection; symptoms include hypertension, headache, edema, oliguria, dark urine, reduced urine output, flank pain, weight gain, fever, chills, nausea, and vomiting; about half of cases are asymptomatic[medi-info.com]
    Dark Urine
    • If symptoms appear, they can include swelling around the feet, ankles, lower legs, and eyes, reduced urination and dark urine (due to the presence of red blood cells in the urine).[drugs.com]
    • Symptoms PSGN Onset of symptoms occurs 1 to 6 weeks after infection; symptoms include hypertension, headache, edema, oliguria, dark urine, reduced urine output, flank pain, weight gain, fever, chills, nausea, and vomiting; about half of cases are asymptomatic[medi-info.com]
    Macroscopic Hematuria
    • Microscopic hematuria is not the norm, but may occur in up to 25% of patients, and macroscopic hematuria is decidedly rare.[clevelandclinicmeded.com]
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  • Eyes
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  • cardiovascular
    Hypertension
    • Hypertensive encephalopathy Severe hypertension associated with signs of cerebral dysfunction is a hypertensive emergency requiring immediate aggressive treatment.[sites.google.com]
    • A low-sodium diet may be needed when hypertension is present.[en.wikipedia.org]
    • These will reduce the risk of infections and hypertension.[medicalnewstoday.com]
    • Hypertension in Jordanian children: a retrospective analysis of 70 cases Pediatr.[jpma.org.pk]
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  • musculoskeletal
    Back Pain
    • Learn about this topic in these articles: description In Bright disease Acute glomerulonephritis is characterized by severe inflammation, renal (kidney) insufficiency, swelling, increased blood pressure, and severe back pain.[britannica.com]
    • Hippocrates originally described the manifestation of back pain and hematuria, which lead to oliguria or anuria.[sites.google.com]
    • Background Hippocrates originally described the natural history of acute GN, writing of back pain and hematuria followed by oliguria or anuria.[emedicine.medscape.com]
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  • gastrointestinal
    Nausea
    • Among the signs and symptoms of acute proliferative glomerulonephritis are the following: Hematuria: Oliguria Edema Hypertension Fever, headache, malaise, anorexia, nausea.[en.wikipedia.org]
    • Loss of appetite, nausea, vomiting, abdominal pain, and joint pain are also common.[merckmanuals.com]
    • […] legs or ankles or other parts of the body, due to fluid accumulation (edema) Shortness of breath during exertion due to anemia Headache or other symptoms of high blood pressure In severe cases, symptoms of kidney failure, including fatigue; seizures; nausea[healthcommunities.com]
    • Symptoms PSGN Onset of symptoms occurs 1 to 6 weeks after infection; symptoms include hypertension, headache, edema, oliguria, dark urine, reduced urine output, flank pain, weight gain, fever, chills, nausea, and vomiting; about half of cases are asymptomatic[medi-info.com]
    • […] hypertensive encephalopathy or crescentic glomerulonephritis; children with obesity may have greater renal injuries ( Clin Nephrol 2009;71:632 ) Children age 6 - 10 : nephritic presentation with abrupt onset of hematuria, oliguria, fever, malaise and nausea[pathologyoutlines.com]
    Vomiting
    • […] ankles or other parts of the body, due to fluid accumulation (edema) Shortness of breath during exertion due to anemia Headache or other symptoms of high blood pressure In severe cases, symptoms of kidney failure, including fatigue; seizures; nausea and vomiting[healthcommunities.com]
    • Symptoms PSGN Onset of symptoms occurs 1 to 6 weeks after infection; symptoms include hypertension, headache, edema, oliguria, dark urine, reduced urine output, flank pain, weight gain, fever, chills, nausea, and vomiting; about half of cases are asymptomatic[medi-info.com]
    • Glomerulonephritis commonly affects children causing fever, headache, loss of appetite, vomiting and puffiness of the face and body (oedema).[medical-dictionary.thefreedictionary.com]
    • […] form may include: Blood or protein in the urine (hematuria, proteinuria) High blood pressure Swelling of your ankles or face (edema) Frequent nighttime urination Very bubbly or foamy urine Symptoms of kidney failure include: Lack of appetite Nausea and vomiting[kidney.org]
    • Individuals with more severe cases of the disease may exhibit: fatigue nausea and vomiting shortness of breath disturbed vision high blood pressure swelling, especially noted in the face, hands, feet, and ankles blood and protein in the urine, resulting[encyclopedia.com]
    Abdominal Pain
    • pain Chronic Glomerulonephritis Prevention There is no known way to prevent chronic glomerulonephritis.[healthcommunities.com]
    • Symptoms include: Swollen feet and legs Puffy face and eyes Decrease in urine production Bubbly, cloudy or bloody urine Nausea Shortness of breath Weakness Fatigue Fever Hypertension Loss of appetite Abdominal pain Headaches Visual disturbances Seizures[davita.com]
    • Some symptoms include: blood or excess protein in your urine, which may be microscopic and show up in urine tests high blood pressure swelling in your ankles and face frequent nighttime urination bubbly or foamy urine , from excess protein abdominal pain[healthline.com]
    • […] symptoms of glomerulonephritis are: Blood in the urine (dark, rust-colored, or brown urine) Foamy urine (due to excess protein in the urine) Swelling (edema) of the face, eyes, ankles, feet, legs, or abdomen Symptoms may also include the following: Abdominal[mountsinai.org]
    • Nonspecific symptoms include weakness, fever, abdominal pain, and malaise.[sites.google.com]
    Loss of Appetite
    • […] of appetite; overall itching; headache; easy bruising; frequent hiccups or bleeding; and impaired vision Increased pigmentation of the skin Abdominal pain Chronic Glomerulonephritis Prevention There is no known way to prevent chronic glomerulonephritis[healthcommunities.com]
    • Symptoms include: Swollen feet and legs Puffy face and eyes Decrease in urine production Bubbly, cloudy or bloody urine Nausea Shortness of breath Weakness Fatigue Fever Hypertension Loss of appetite Abdominal pain Headaches Visual disturbances Seizures[davita.com]
    • […] of appetite Joint or muscle aches Nosebleed The symptoms of chronic kidney disease may develop over time.[mountsinai.org]
    • When kidney failure is severe or near end stage, symptoms include: confusion decreased urination fatigue headache high blood pressure itchy skin loss of appetite muscle twitching or cramping nausea and vomiting nosebleeds puffy eyes, hands, and feet ([chealth.canoe.com]
    • […] of appetite and vomiting.[yourkidshealth.net]
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  • neurologic
    Headache
    • […] or other symptoms of high blood pressure In severe cases, symptoms of kidney failure, including fatigue; seizures; nausea and vomiting; loss of appetite; overall itching; headache; easy bruising; frequent hiccups or bleeding; and impaired vision Increased[healthcommunities.com]
    • Among the signs and symptoms of acute proliferative glomerulonephritis are the following: Hematuria: Oliguria Edema Hypertension Fever, headache, malaise, anorexia, nausea.[en.wikipedia.org]
    • If severely elevated blood pressure develops, some people will have headaches (although most people with high blood pressure have no symptoms and most headaches are unrelated to blood pressure).[drugs.com]
    • […] burst blood vessels in the retina of the eye Cough containing mucus or pink, frothy material from fluid buildup in the lungs Shortness of breath, from fluid buildup in the lungs General ill feeling (malaise), drowsiness , confusion , aches and pains, headache[nlm.nih.gov]
    Guillain-Barré Syndrome
    • Miscellaneous noninfectious causes of acute GN include the following: Guillain-Barré syndrome Irradiation of Wilms tumor Diphtheria-pertussis-tetanus (DPT) vaccine Serum sickness Epidermal growth factor receptor activation, [ 8 ] and possibly its inhibition[emedicine.medscape.com]
    • Differential Diagnoses Amyloidosis, Familial Renal Pediatrics, Fever Angioedema Pediatrics, Pharyngitis Ascites Pharyngitis Cirrhosis Renal Failure, Acute Diabetes Mellitus, Type 2 Rheumatic Fever Guillain-Barré Syndrome Scarlet Fever Heart Failure Serum[sites.google.com]
    Papilledema
    • Other signs and symptoms were fever 19%, arthralgia 4%, epistaxis 6% and bilateral papilledema 1% (Figure 3).[jpma.org.pk]
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  • Face, Head & Neck
    Facial Edema
    • Facial edema, or swelling, is common which tends to be more prominent in the morning.[yourkidshealth.net]
    • Most often, the patient is a boy, aged 2-14 years, who suddenly develops puffiness of the eyelids and facial edema in the setting of a poststreptococcal infection.[sites.google.com]
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  • Entire body system
    Fever
    • Acute glomerulonephritis in dengue hemorrhagic fever: A rare case report.[atmph.org]
    • Crescentic type Similar to PSGN, but the onset is more insidious and weakness, fatigue, and fever are the predominant symptoms IgA neuropathy Similar to PSGN, but the onset usually occurs 1 to 2 days after upper respiratory infection or enteral illness[medi-info.com]
    • Among the signs and symptoms of acute proliferative glomerulonephritis are the following: Hematuria: Oliguria Edema Hypertension Fever, headache, malaise, anorexia, nausea.[en.wikipedia.org]
    • (MJA 2011; 195: 150-152) A 10-year-old boy from a remote village in Western Province, Papua New Guinea (PNG), presented to Saibai Island Primary Health Centre in the northern Torres Strait, Queensland, with a 4-year history of intermittent malaise, fevers[mja.com.au]
    • Differential Diagnoses Amyloidosis, Familial Renal Pediatrics, Fever Angioedema Pediatrics, Pharyngitis Ascites Pharyngitis Cirrhosis Renal Failure, Acute Diabetes Mellitus, Type 2 Rheumatic Fever Guillain-Barré Syndrome Scarlet Fever Heart Failure Serum[sites.google.com]
    Rapidly Progressive Glomerulonephritis
    • Rapidly progressive glomerulonephritis For rapidly progressive glomerulonephritis, drugs to suppress the immune system are started promptly.[merckmanuals.com]
    • progressive glomerulonephritis, 1 - 2% develop chronic glomerulonephritis Poor prognosis more likely if massive proteinuria and abnormal GFR; 2 - 5% die from pulmonary edema, hypertensive encephalopathy or crescentic glomerulonephritis; children with[pathologyoutlines.com]
    • People with rapidly progressive glomerulonephritis may present with a nephritic syndrome .[en.wikipedia.org]
    • This is called rapidly progressive glomerulonephritis.[mountsinai.org]
    • Idiopathic rapidly progressive glomerulonephritis is a form of glomerulonephritis characterized by the presence of glomerular crescents.[sites.google.com]
    Malaise
    • Among the signs and symptoms of acute proliferative glomerulonephritis are the following: Hematuria: Oliguria Edema Hypertension Fever, headache, malaise, anorexia, nausea.[en.wikipedia.org]
    • (MJA 2011; 195: 150-152) A 10-year-old boy from a remote village in Western Province, Papua New Guinea (PNG), presented to Saibai Island Primary Health Centre in the northern Torres Strait, Queensland, with a 4-year history of intermittent malaise, fevers[mja.com.au]
    • […] that may occur include: Blurred vision , usually from burst blood vessels in the retina of the eye Cough containing mucus or pink, frothy material from fluid buildup in the lungs Shortness of breath, from fluid buildup in the lungs General ill feeling (malaise[nlm.nih.gov]
    • […] pulmonary edema, hypertensive encephalopathy or crescentic glomerulonephritis; children with obesity may have greater renal injuries ( Clin Nephrol 2009;71:632 ) Children age 6 - 10 : nephritic presentation with abrupt onset of hematuria, oliguria, fever, malaise[pathologyoutlines.com]
    Congestive Heart Failure
    • heart failure, acute or chronic renal failure, and end-stage renal disease.[medi-info.com]
    • This is secondary to congestive heart failure and azotemia.[emedicine.medscape.com]
    • The following conditions can also occur due to GN: acute kidney failure chronic kidney disease electrolyte imbalances, such as high levels of sodium or potassium chronic urinary tract infections congestive heart failure due to retained fluid or fluid[healthline.com]
    • If left untreated, glomerulonephritis can lead to chronic renal failure, end-stage renal disease, high blood pressure, congestive heart failure, pulmonary edema, and an increased risk of other infections, especially urinary tract and kidney infections[chealth.canoe.com]
    Weight Gain
    • Symptoms PSGN Onset of symptoms occurs 1 to 6 weeks after infection; symptoms include hypertension, headache, edema, oliguria, dark urine, reduced urine output, flank pain, weight gain, fever, chills, nausea, and vomiting; about half of cases are asymptomatic[medi-info.com]
    • Despite corticosteroids being effective, in many patients high doses for prolonged periods can have significant side affects including: weight gain, hyperglycemia, destruction of bones, easy bruising, and thinning of the skin.[nephrocor.com]
    • During your physical examination, your doctor will measure your blood pressure, weigh you to check for weight gain resulting from water retention, and check for swelling in your legs or elsewhere.[drugs.com]
    • Although effective, in many patients, at high doses, for long periods of time, these agents have significant side affects including : weight gain, hyperglycemia, and agitation, destruction of bones, easy bruising, and thinning of the skin.[hopkinsmedicine.org]
    • Other signs Pharyngitis Impetigo Respiratory infection Pulmonary hemorrhage Heart murmur may indicate endocarditis Scarlet fever Weight gain Abdominal pain Anorexia Back pain Skin pallor Palpable purpura in patients with Henoch-Schönlein purpura Oral[sites.google.com]
    Pallor
    • Signs and Symptoms The signs and symptoms of this disorder is fever, lethargy, irritability, fatigue (from anemia), hematuria ( blood in the urine), proteinuria (protein in the urine), scanty urine output, headache, high blood pressure, pallor, abdominal[yourkidshealth.net]
    • Other signs Pharyngitis Impetigo Respiratory infection Pulmonary hemorrhage Heart murmur may indicate endocarditis Scarlet fever Weight gain Abdominal pain Anorexia Back pain Skin pallor Palpable purpura in patients with Henoch-Schönlein purpura Oral[sites.google.com]
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  • Course
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  • Workup

    No symptom or sign is pathognomonic of AGN. Laboratory tests are, therefore, necessary to confirm a suspected case of AGN.

    Urinalysis is necessary and may reveal red blood cell and white blood cell casts. Red blood cell casts are indicative of glomerular damage while the white cell casts are indicative of infection or inflammation of the nephron. Urinalysis also reveals proteinuria. Blood investigations necessary for diagnosis are tests for creatinine and urea levels.

    Imaging studies such as abdominal plain radiographs, ultrasonography, and computed tomography (CT) scans may be necessary. However, a kidney biopsy is the definitive diagnostic modality to confirm AGN [12].

    Pathology

    Biopsy
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  • Laboratory

    Serum
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  • Imaging

    X-ray
    Congestive Heart Failure
    • heart failure, acute or chronic renal failure, and end-stage renal disease.[medi-info.com]
    • This is secondary to congestive heart failure and azotemia.[emedicine.medscape.com]
    • The following conditions can also occur due to GN: acute kidney failure chronic kidney disease electrolyte imbalances, such as high levels of sodium or potassium chronic urinary tract infections congestive heart failure due to retained fluid or fluid[healthline.com]
    • If left untreated, glomerulonephritis can lead to chronic renal failure, end-stage renal disease, high blood pressure, congestive heart failure, pulmonary edema, and an increased risk of other infections, especially urinary tract and kidney infections[chealth.canoe.com]
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  • Treatment

    The management of AGN involves treatment of the underlying trigger, supportive care, and conservative management of the complications of the disease.

    Diuretics are necessary to resolve the edema and antihypertensives are equally vital [13]. Furthermore, dietary modifications should consist of low protein diet and salt restriction. Antibiotics are administered in cases of infectious AGN, however, antibiotics may be ineffective since the nephritis occurs 1 to 6 weeks after the inciting infection. Typically, the infection resolves before the onset of the nephritis, however, if the infection still persists, antibiotics can be administered.

    Corticosteroids are administered in cases of AGN triggered by autoimmune disease and in rapidly progressive glomerulonephritis. High dose corticosteroids are administered intravenously for up to 7 days after which they are switched to oral forms. Immunosuppressants may also be beneficial for these patients [14]. Plasmapheresis may also be a beneficial procedure to clear off antibodies from the blood. 

    Generally, prompt diagnosis and treatment prevents progression of the disease to ESRD. Renal transplantation is the definitive treatment for ESRD; however, rapidly progressive glomerulonephritis may reappear in the transplanted kidney.

    Prognosis

    Post-streptococcal glomerulonephritis and IgA nephropathy have a minimal risk of progressing to chronic kidney disease if the underlying pathology is treated well in time. Complete resolution of symptoms is observed in most patients, especially children.

    For other glomerular pathologies, the outcome is generally better if the patient presents with asymptomatic hematuria open link and proteinuria and in those with focal instead of diffuse glomerular changes on renal biopsy. Patients with diffuse glomerular involvement usually have a poorer prognosis.

    Generally, poor prognostic factors include severe proteinuria, severe renal dysfunction, unresponsiveness to treatment, and extensive fibrotic changes in the glomeruli such as glomerulosclerosis.

    If patients having membranoproliferative disease remain untreated, 50-60% of them will lead to ESRD in a period of 10-15 years. The situation in case of Wegener granulomatosis is different because about 20-25% are at risk of leading to ESRD [9] [10]. 

    Complications

    Proteinuria
    • Monitor degree of proteinuria to determine therapeutic success.[clevelandclinicmeded.com]
    • One of Cohen and Levitt's cases had no hematuria and essentially no proteinuria.[annals.org]
    • The 24-hour urine collection confirmed a nephrotic range proteinuria of 4.5 g/day.[scielo.br]
    • IgA glomerulonephritis IgA nephropathy; a chronic form marked by a hematuria and proteinuria and by deposits of immunoglobulin A in the mesangial areas of the renal glomeruli, with subsequent reactive hyperplasia of mesangial cells. lobular glomerulonephritis[medical-dictionary.thefreedictionary.com]
    • Erythematosus (SLE); Amyloidosis; Diabetic glomerulopathy; HIV-associated nephropathy; Sickle-Cell disease The onset of symptoms for GN occur about 10 days from the time of infection. normally recover quickly and completely Results for glomerular injury proteinuria[quizlet.com]
    Fever
    • Acute glomerulonephritis in dengue hemorrhagic fever: A rare case report.[atmph.org]
    • Crescentic type Similar to PSGN, but the onset is more insidious and weakness, fatigue, and fever are the predominant symptoms IgA neuropathy Similar to PSGN, but the onset usually occurs 1 to 2 days after upper respiratory infection or enteral illness[medi-info.com]
    • Among the signs and symptoms of acute proliferative glomerulonephritis are the following: Hematuria: Oliguria Edema Hypertension Fever, headache, malaise, anorexia, nausea.[en.wikipedia.org]
    • (MJA 2011; 195: 150-152) A 10-year-old boy from a remote village in Western Province, Papua New Guinea (PNG), presented to Saibai Island Primary Health Centre in the northern Torres Strait, Queensland, with a 4-year history of intermittent malaise, fevers[mja.com.au]
    • Differential Diagnoses Amyloidosis, Familial Renal Pediatrics, Fever Angioedema Pediatrics, Pharyngitis Ascites Pharyngitis Cirrhosis Renal Failure, Acute Diabetes Mellitus, Type 2 Rheumatic Fever Guillain-Barré Syndrome Scarlet Fever Heart Failure Serum[sites.google.com]
    Acute Kidney Failure
    • kidney failure or chronic kidney disease may develop.[nlm.nih.gov]
    • Possible complications of glomerulonephritis include: Acute kidney failure.[mayoclinic.org]
    • The following conditions can also occur due to GN: acute kidney failure chronic kidney disease electrolyte imbalances, such as high levels of sodium or potassium chronic urinary tract infections congestive heart failure due to retained fluid or fluid[healthline.com]
    Rapidly Progressive Glomerulonephritis
    • Rapidly progressive glomerulonephritis For rapidly progressive glomerulonephritis, drugs to suppress the immune system are started promptly.[merckmanuals.com]
    • progressive glomerulonephritis, 1 - 2% develop chronic glomerulonephritis Poor prognosis more likely if massive proteinuria and abnormal GFR; 2 - 5% die from pulmonary edema, hypertensive encephalopathy or crescentic glomerulonephritis; children with[pathologyoutlines.com]
    • People with rapidly progressive glomerulonephritis may present with a nephritic syndrome .[en.wikipedia.org]
    • This is called rapidly progressive glomerulonephritis.[mountsinai.org]
    • Idiopathic rapidly progressive glomerulonephritis is a form of glomerulonephritis characterized by the presence of glomerular crescents.[sites.google.com]
    Congestive Heart Failure
    • heart failure, acute or chronic renal failure, and end-stage renal disease.[medi-info.com]
    • This is secondary to congestive heart failure and azotemia.[emedicine.medscape.com]
    • The following conditions can also occur due to GN: acute kidney failure chronic kidney disease electrolyte imbalances, such as high levels of sodium or potassium chronic urinary tract infections congestive heart failure due to retained fluid or fluid[healthline.com]
    • If left untreated, glomerulonephritis can lead to chronic renal failure, end-stage renal disease, high blood pressure, congestive heart failure, pulmonary edema, and an increased risk of other infections, especially urinary tract and kidney infections[chealth.canoe.com]
    Hypertension
    • Hypertensive encephalopathy Severe hypertension associated with signs of cerebral dysfunction is a hypertensive emergency requiring immediate aggressive treatment.[sites.google.com]
    • A low-sodium diet may be needed when hypertension is present.[en.wikipedia.org]
    • These will reduce the risk of infections and hypertension.[medicalnewstoday.com]
    • Hypertension in Jordanian children: a retrospective analysis of 70 cases Pediatr.[jpma.org.pk]
    Hypertensive Encephalopathy
    • encephalopathy or crescentic glomerulonephritis; children with obesity may have greater renal injuries ( Clin Nephrol 2009;71:632 ) Children age 6 - 10 : nephritic presentation with abrupt onset of hematuria, oliguria, fever, malaise and nausea 1 - 4[pathologyoutlines.com]
    • Drug treatments are usually effective, and very few individuals die as a result of pulmonary edema, brain inflammation (hypertensive encephalopathy ), or uncontrolled infection.[mdguidelines.com]
    • Hypertensive encephalopathy and pulmonary congestion are treated with parenteral drugs 8 .[jpma.org.pk]
    Malignant Hypertension
    • Diabetes mellitus Malignant hypertension (high blood pressure) Amyloidosis Inherited diseases like Alport’s syndrome.[healthhype.com]
    • Headache may occur secondary to hypertension; confusion secondary to malignant hypertension may be seen in as many as 5% of patients.[sites.google.com]
    Edema
    • Circulatory congestion and pulmonary edema The patient often presents with only mild edema.[sites.google.com]
    • These complexes trigger many inflammatory mediators, such as complement, white blood cells, and blood clotting proteins, which cause damage to kidney tissue Actions that cause tissue injury to kidneys damage to cell membranes, local edema, movement of[quizlet.com]
    • […] and hypertension Adults : may have atypical presentation with sudden hypertension, edema and elevated BUN; 60% recover, others develop rapidly progressive glomerulonephritis ( Arab J Nephrol Transplant 2012;5:93 , J Med Assoc Thai 2006;89 Suppl 2:S157[pathologyoutlines.com]
    • The disease may result in hypertension, edema, and kidney failure .[mdguidelines.com]
    • ., B.P. 140/90 in 42%, encephalopathy 5%, congestive cardiac failure 3% and pulmonary edema 1%.[jpma.org.pk]
    Renal Vasculitis
    • Néphrologie 20:65–74 PubMed Google Scholar Elzouki AY, Akthar M, Mirza K (1996) Brucella endocarditis associated with glomerulonephritis and renal vasculitis.[link.springer.com]
    Rheumatic Fever
    • Systematic Review: Estimation of global burden of non-suppurative sequelae of upper respiratory tract infection: rheumatic fever and post-streptococcal glomerulonephritis.[emedicine.medscape.com]
    • Differential Diagnoses Amyloidosis, Familial Renal Pediatrics, Fever Angioedema Pediatrics, Pharyngitis Ascites Pharyngitis Cirrhosis Renal Failure, Acute Diabetes Mellitus, Type 2 Rheumatic Fever Guillain-Barré Syndrome Scarlet Fever Heart Failure Serum[sites.google.com]
    Guillain-Barré Syndrome
    • Miscellaneous noninfectious causes of acute GN include the following: Guillain-Barré syndrome Irradiation of Wilms tumor Diphtheria-pertussis-tetanus (DPT) vaccine Serum sickness Epidermal growth factor receptor activation, [ 8 ] and possibly its inhibition[emedicine.medscape.com]
    • Differential Diagnoses Amyloidosis, Familial Renal Pediatrics, Fever Angioedema Pediatrics, Pharyngitis Ascites Pharyngitis Cirrhosis Renal Failure, Acute Diabetes Mellitus, Type 2 Rheumatic Fever Guillain-Barré Syndrome Scarlet Fever Heart Failure Serum[sites.google.com]
    Glomerulonephritis
    • Acute proliferative glomerulonephritis is a disorder of the glomeruli (glomerulonephritis), or small blood vessels in the kidneys.[en.wikipedia.org]
    • See Acute glomerulonephritis , Capsular 'drops. ', Casts, Chronic glomerulonephritis, Heymann glomerulonephritis, Membranoproliferative glomerulonephritis type 1 and 2, Membranous glomerulonephritis, Mesangial proliferative glomerulonephritis, Crescents[medical-dictionary.thefreedictionary.com]
    • Chronic glomerulonephritis Often, chronic glomerulonephritis seems to result from some of the same conditions that cause acute glomerulonephritis, such as IgA nephropathy or membranoproliferative glomerulonephritis.[merckmanuals.com]
    • (diagnosis) , glomerulonephritis , Nephritis-glomerular , Glomerulonephritis NOS , glomerulonephritis NOS , Glomerulonephritis [Disease/Finding] , glomerulonephritides , Unspecified glomerulonephritis NOS (disorder) , GN - Glomerulonephritis , Glomerulonephritis[fpnotebook.com]
    Scarlet Fever
    • Scarlet fever, and impetigo 5.[proprofs.com]
    • In children, it is most often associated with an upper respiratory infection, tonsillitis, or scarlet fever.[encyclopedia.com]
    • Sixty-eight chil­dren had clinical evidence of acute pharyngitis, 12 had an ASO titer of 500 Todd units without a history of a “sore throat”, 7 gave a history of Scarlet fever and 3 had impetigo.[jpma.org.pk]
    • In children, it is most often associated with an upper respiratory infection, tonsillitis , or scarlet fever .[medical-dictionary.thefreedictionary.com]
    • Poststreptococcal glomerulonephritis was first recognized as a complication of the convalescence period of scarlet fever in the 18th century. [1] A link between hemolytic streptococci and acute glomerulonephritis was recognized in the 20th century.[emedicine.medscape.com]

    Etiology

    The etiological factors responsible for AGN may be classified into infectious and non-infectious causes. The commonest infections responsible for AGN are streptococcal infections, particularly strep pharyngitis.

    Noninfectious causes of AGN are mostly autoimmune diseases and include systemic lupus erythematosus (SLE), goodpasture's syndrome, amyloidosis, Wegener granulomatosis, and polyarteritis nodosa [3].

    Prolonged and heavy use of nonsteroidal anti-inflammatory drugs (NSAIDs) have also been suggested as a risk factor for AGN.

    Causes

    Congestive Heart Failure
    • heart failure, acute or chronic renal failure, and end-stage renal disease.[medi-info.com]
    • This is secondary to congestive heart failure and azotemia.[emedicine.medscape.com]
    • The following conditions can also occur due to GN: acute kidney failure chronic kidney disease electrolyte imbalances, such as high levels of sodium or potassium chronic urinary tract infections congestive heart failure due to retained fluid or fluid[healthline.com]
    • If left untreated, glomerulonephritis can lead to chronic renal failure, end-stage renal disease, high blood pressure, congestive heart failure, pulmonary edema, and an increased risk of other infections, especially urinary tract and kidney infections[chealth.canoe.com]
    Hypertension
    • Hypertensive encephalopathy Severe hypertension associated with signs of cerebral dysfunction is a hypertensive emergency requiring immediate aggressive treatment.[sites.google.com]
    • A low-sodium diet may be needed when hypertension is present.[en.wikipedia.org]
    • These will reduce the risk of infections and hypertension.[medicalnewstoday.com]
    • Hypertension in Jordanian children: a retrospective analysis of 70 cases Pediatr.[jpma.org.pk]

    Epidemiology

    AGN accounts for 10-15% cases of glomerular diseases in the United States. However, the incidence rates have been variable, partially because of the asymptomatic nature of this condition in more than 50% of patients. Generally, statistics reveal a decline in the incidence of post-streptococcal glomerulonephritis in the United States. This decline is attributable to improved healthcare delivery and socioeconomic conditions.

    In the United States, AGN is responsible for 25-30% of cases of ESRD. In about 25% of cases, the disease progresses to an acute nephritic syndrome. Acute nephritic syndrome, in turn, progresses to end-stage renal failure after several weeks or months.

    Worldwide, the commonest cause of AGN is Berger disease or IgA nephropathy. Post-streptococcal glomerulonephritis open link is most commonly seen in Africa, the Caribbean, India, South America, Malaysia, and Pakistan.

    In Nigeria's Port Harcourt city, the incidence of AGN in children between the ages of 3 to 16 years was 15.5 cases per year. Furthermore, the incidence of the disease was higher among males than females with a ratio of 1.1:1. However, currently the difference in incidence among males and females is not so significant [4].

    Generally, there are more marked variations in geographic and seasonal incidence rates of post-streptococcal glomerulonephritis following pharyngeal infections than those which follow streptococcal skin infections [4] [5].

    Sex distribution
    Age distribution

    Pathophysiology

    AGN presents with both morphological and functional changes in the kidneys. There is cellular proliferation in the glomerular tufts as a result of the excess proliferation of the mesangial, epithelial, and endothelial cells triggered by the immune-complex deposition [6]. The cellular proliferation may be confined to the glomerular capillary, in what's described as endocapillary proliferation. Alternatively, it may occur in the Bowman's capsule beyond the glomerular cells and it is referred to as extra capillary proliferation. Accompanying this cellular proliferation is neutrophilic and monocytic infiltration of the glomerular capillary lumen.

    On light microscopy, the glomerular capillary walls appear thickened. A study using electron microscopy clearly shows the basement membrane as thickened due to the deposits of electron-dense particles on the subendothelial, mesangial, and subepithelial parts of the basement membrane. The structural changes in the kidneys may be focal, segmental, diffuse, or global. Morphologically the kidneys appear grossly enlarged as a result of swelling effect in the glomerular tufts.

    The main feature of AGN is the deposition or formation of immune complexes in the glomerulus. The deposition of complement factors and immunoglobulins is demonstrable by immunofluorescence.

    The triggers for the formation of immune complexes in the glomerulus are largely unclear, except in cases of post-streptococcal glomerulonephritis. In post-streptococcal glomerulonephritis, a streptococcal neuraminidase alters the host immunoglobulin G (IgG) which combines with the host antibodies forming IgG/anti-IgG complexes which subsequently deposit in the glomeruli. Furthermore, the presence of high titers of antistreptolysin O or antihyaluronidase, streptokinase, and DNAase-B strongly suggest a preceding streptococcal infection. Specific antibodies may combine with these antigens to form immune complexes.

    Nephritis-associated plasmin receptor (NAPlr) has been described as a glyceraldehyde-3-phosphate dehydrogenase which functions a plasminogen receptor. NAPlr deposition was demonstrated in the initial stages of post-streptococcal glomerulonephritis in immunofluorescence staining of renal biopsy specimens with anti-NAPlr antibodies. This finding links NAPlr with the pathogenesis of post-streptococcal glomerulonephritis [7].

    A study conducted among adults revealed that the two commonest infectious triggers of AGN were streptococci and staphylococci, occurring in 27.9% and 24.4% of cases, respectively [8]. In infections of groups A, C, and G streptococcus associated with glomerulonephritis, titers of antibodies against nephritis-associated protease (NAPR) are significantly elevated. Anti-NAPR antibodies persist for several years and have been suggested to help prevent further episodes of post-streptococcal glomerulonephritis.

    Prevention

    Prevention of AGN may include routine urinalysis done for patients with autoimmune diseases such as SLE.

    Summary

    Acute glomerulonephritis (AGN) is inflammation of the glomeruli which occurs as a result of autoimmune response to an infection or immune complex depositions occurring in autoimmune pathologies. AGN may also affect the various parts of glomerulus such as mesangium, the capillary endothelium and basement membrane.

    Generally, the causes of AGN may be infectious or autoimmune diseases. AGN often occurs sequel to a streptococcal infection open link, usually strep throat or strep cutaneous infections [1]. This post-streptococcal glomerulonephritis is often commonly seen in children between 2 and 10 years. Noninfectious causes of AGN include autoimmune diseases such as IgA nephropathy, systemic lupus erythematosus, cryoglobulinemia, goodpasture syndrome, and Wegener granulomatosis [2]. AGN due to these autoimmune diseases is most likely associated with rapidly progressive glomerulonephritis.

    The characteristic features of AGN are the formation and deposition of immune complexes in the glomerular tufts, accompanied by polymorphonuclear cellular infiltrates. Functionally, AGN results in hematuria, proteinuria, facial or pedal edema, and systemic hypertension. Nonspecific symptoms are also common in this disease.

    Disease prognosis becomes poor due to severe proteinuria, hematuria, and renal damage on presentation, unresponsiveness to appropriate therapy, and the presence of extensive renal fibrosis or sclerosis on biopsy. The main complication of AGN is the end-stage renal disease (ESRD).

    Renal biopsy is the main diagnostic tool of choice to confirm AGN. However, other investigations including bloodwork, urinalysis, and imaging studies provide details to corroborate the diagnosis.

    Management of AGN comprises of symptomatic control and treatment of the underlying disorder. Antibiotics and corticosteroids are administered for infectious and autoimmune-associated AGN, respectively. Additionally, diuretics are necessary to relieve the edema. 

    Patient Information

    Overview

    The kidney is an organ of waste excretion in the form of urine. However, the process of waste excretion is very complex involving several small structures within each kidney. The first stage of urine production is the filtration of the waste products from the blood. Some useful products are also filtered, but are later reabsorbed into the blood. The units which filter the blood are called the glomeruli (singular: glomerulus).

    Acute glomerulonephritis (AGN) is an inflammation and consequent destruction of the glomeruli and adjacent tissues. This, in turn, would lead to reduced urine production as well as salt and water retention in the body.

    Etiology

    AGN may be caused by infections or certain noninfectious diseases called autoimmune diseases in which the body's antibodies attack certain normal tissues in the body confusing them for foreign harmful substances. The commonest infectious causes of AGN are infections caused by the bacterium streptococcus, which are mostly are responsible for sore throat and skin infections. The common autoimmune diseases which cause AGN includes systemic lupus erythematosus (SLE), Wegener granulomatosis, and Berger disease.

    Pathophysiology

    AGN develops when antibodies formed in the body against certain components of the bacterium or infectious agents bind with these agents and deposit in the glomeruli causing destruction of the glomeruli and surrounding tissues.

    Presentation

    More than half of the patients with this disease may not show any symptoms. However, those who come down with symptoms may present with swelling of the face and legs, reduced urine volume, passage of coke-colored or dark urine, urine frothiness and a high blood pressure.

    The facial and leg swelling results from the kidneys' inability to dilute the urine with water from the blood and so there is an accumulation of excess salt and water in the certain regions of the body such as the feet and face. This is also responsible for the elevated blood pressure in these patients. The dark color of the urine is due to the presence of the blood in it, and the frothiness of the urine is as a result of leakage of small proteins through the damaged glomerular filter into the urine. 

    There are other non-specific symptoms of this disease which include fever, weakness, dizziness, and abdominal aches.

    Diagnosis

    A diagnosis of AGN is made by way of investigations which include blood tests and urinalysis: which involves examining a sample of the patient's urine and analyzing it's contents. Results of urinalysis in AGN usually show presence of white and red blood cells which indicate infective damage or inflammation of the kidney tubules and damage to the glomeruli, respectively.

    The main diagnostic tool for confirming the diagnosis of AGN is kidney biopsy. This procedure involves using a big needle to take a sample of the kidney through the patient's trunk, then analyzing the sample under a microscope.

    Treatment

    Prompt diagnosis and treatment of AGN is necessary to avoid the major complication which is called end-stage renal disease which indicates that the kidney is too damaged to function at all.

    Treatment of AGN involves treating the predisposing condition and correcting the symptoms. A class of drugs called diuretics are prescribed to remove excess fluids from the sites where they accumulate. Drugs which lower blood pressure are also necessary. If an infection is determined as the trigger of AGN, antibiotics are administered and for autoimmune-related cases, drugs called corticosteroids such as prednisolone are administered.

    In cases of end-stage renal disease, kidney transplant is considered.

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    References

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    2. Emancipator SN. IgA nephropathy: morphological expression and pathogenesis. Am J Kidney Dis. 1994; 23:451-462.
    3. Kalluri R, Wilson CV, Weber M, et al. Identification of the α-3 chain of type IV collagen as the common autoantigen in anti-glomerular basement membrane disease and Goodpasture’s syndrome. J Am Soc Nephrol. 1995; 6:1178-1184.
    4. Anochie I, Eke F, Okpere A. Childhood acute glomerulonephritis in Port Harcourt, Rivers State, Nigeria. Niger J Med. 2009; 18(2):162-167.
    5. Wong W, Morris MC, Zwi J. Outcome of severe acute post-streptococcal glomerulonephritis in New Zealand children. Pediatr Nephrol. 2009; 24(5):1021-1026.
    6. Wen YK, Chen ML. The significance of atypical morphology in the changes of spectrum of postinfectious glomerulonephritis. Clin Nephrol. 2010; 73(3):173-179. 
    7. Oda T, Yoshizawa N, Yamakami K, et al. The role of nephritis-associated plasmin receptor (NAPlr) in glomerulonephritis associated with streptococcal infection. J Biomed Biotechnol. 2012; 2012:417675.
    8. Nasr SH, Markowitz GS, Stokes MB, et al. Acute postinfectious glomerulonephritis in the modern era: experience with 86 adults and review of the literature. Medicine (Baltimore). 2008; 87(1):21-32.
    9. Donadio JV Jr, Offord KP. Reassessment of treatment results in membranoproliferative glomerulonephritis, with emphasis on life-table analysis. Am J Kidney Dis. 1989; 14:445-451.
    10. Andrassy K, Erb A, Koderisch J, et al. Wegener's granulomatosis with renal involvement: patient survival and correlations between initial renal function, renal histology, therapy and renal outcome. Clin Nephrol. 1991; 35:139-147.
    11. Sad RA, Said SM. Hypertension in Jordanian children: a retrospective analysis of 70 cases Pediatr. Nephrol. 1990; 4:520-522.
    12. Nebuloni M, Barbiano di Belgiojoso G, Genderini A, et al. Glomerular lesions in HIV-positive patients: a 20-year biopsy experience from Northern Italy. Clin Nephrol. 2009; 72(1):38-45.
    13. Tapaneyaand O. AGN in children: a prospective study. J Med Assoc Thai. 1989; 72(suppl):35-38.
    14. Wong W, Morris MC, Zwi J. Outcome of severe acute post-streptococcal glomerulonephritis in New Zealand children. Pediatr Nephrol. 2009; 24(5):1021-1026.

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