Clinical Features of Acute Glomerulonephritis

Often, the patient is a young boy, typically between 2 and 14 years old, who experiences a sudden onset of puffiness around the eyelids and facial swelling following a streptococcal infection. Their urine may appear dark and reduced in volume, and their blood pressure might be elevated.

1. The start of symptoms is usually sudden and noticeable.

2. Patients may experience general and non-specific symptoms such as weakness, fever, abdominal discomfort, and a feeling of being unwell (malaise).

3. The onset is typically abrupt, with a preceding history of a sore throat or skin infection. Patients may also have an elevated temperature, headache, and vomiting.

4. Swelling of the body, particularly in the face and lower legs, tends to be more pronounced in the mornings after waking due to the effects of gravity during sleep.

5. There may be tenderness in the area where the ribs meet the spine (costovertebral angle) and pain in the flank, which can sometimes be described as similar to the pain of kidney stones (renal colic).

6. Blood in the urine (hematuria) is a consistent finding, even if it’s only visible under a microscope. Visible (gross) hematuria is reported in approximately 30% of children affected.

7. Reduced urine output (oliguria) is common.

8. Swelling (edema), either in the extremities or around the eyes (periorbital), is seen in about 85% of children. The swelling can range from mild (just the face).

9. High blood pressure (hypertension) frequently develops. In severe cases, the blood pressure can be extremely high, leading to a severe headache, rapid heartbeat (palpitations), getting tired easily, vision problems, vomiting, and even seizures (hypertensive encephalopathy).

10. There may be signs and symptoms suggestive of heart failure.

11. As the condition progresses, the patient may experience shortness of breath, tiredness (lethargy), and loss of appetite (anorexia).

12. Headache can occur as a result of the high blood pressure. Confusion due to dangerously high blood pressure might be seen in around 5% of patients.

13. Shortness of breath or difficulty breathing on exertion (dyspnea) can occur due to heart failure or fluid buildup in the lungs (pulmonary edema), although this is less common, especially in children.

14. Pain in the side (flank) is possible due to the stretching of the outer covering of the kidney (renal capsule).

15. Changes in urine:

    • Decreased urine output (oliguria).

    • Microscopic blood in the urine, making it appear dark, concentrated, and smoky.

    • Protein (albumin) is almost always present in significant amounts.

    • Casts (microscopic cylindrical structures formed in the kidney tubules) may be present and visible under a microscope.

Clinical Features Summary

• Abrupt onset of symptoms.

• Typically affects children aged 4 to 12 years, and is more common in males than females (M>F).

• There’s a delay (latent period) between the infection and the kidney problems:

  • Throat infection: 1 to 2 weeks.

  • Skin infection: 3 to 6 weeks.

• HEMATURIA (Blood in the urine):

  • Appears smoky brown or cola-colored.

  • Indicates a problem in the glomeruli, with abnormally shaped red blood cells (dysmorphic RBCs) and casts visible in freshly examined urine.

• PROTEINURIA (Protein in the urine):

  • Usually mild to moderate, but reaching levels seen in nephrotic syndrome is rare.

• OLIGURIA (Reduced urine output):

  • Temporary in about 50% of cases; complete absence of urine (anuria) is rare.

• EDEMA (Swelling): Occurs in 85% of cases.

  • Mild: Affecting the area around the eyes (periorbital) or feet and ankles (pedal).

  • Severe: Associated with high blood pressure, fluid buildup around the lungs (pleural effusion), or fluid in the abdominal cavity (ascites).

  • In adolescents, swelling is more likely to be seen in the face and legs.

• HYPERTENSION (High blood pressure): Present in 80% of cases.

  • Can cause headache, drowsiness (somnolence).

  • May lead to changes in mental status.

  • Can result in loss of appetite, nausea, and seizures.

  • HYPERTENSIVE EMERGENCY: Occurs in about 10% of cases.

    • Blood pressure is more than 30% higher than normal for their age and sex.

    • There is evidence of brain dysfunction due to high blood pressure (encephalopathy).

    • Heart failure or fluid buildup in the lungs may be present.

• AZOTEMIA: There are varying degrees of waste buildup in the blood.

• CIRCULATORY CONGESTION: Occurs in 20% of cases.

  • Symptoms include shortness of breath (dyspnea), difficulty breathing when lying down (orthopnea).

  • May involve cough, rapid heartbeat (tachycardia), an extra heart sound (gallop rhythm).

  • Can progress to congestive heart failure (CCF) and pulmonary edema.

Diagnosis

In cases of acute nephritis following an infection, there’s typically a delay of up to 3 weeks before symptoms appear. This delay can vary, usually 1 to 2 weeks after a throat infection and 2 to 4 weeks after a skin infection.

The onset of nephritis within 1 to 4 days of a streptococcal infection suggests the possibility of pre-existing kidney disease.

Diagnostic tests include:

• Urine analysis (Urinalysis): To check for protein, pus cells, red blood cells, and red blood cell casts under a microscope. It will also show if proteins are present and may show glucose.

• Blood tests: To measure urea and creatinine levels (to assess kidney function) and electrolyte levels.

• Ultrasound scan of the kidneys: To visualize the structure of the kidneys.

• Blood pressure measurement.

• Throat and skin swabs: Collected and sent for culture and sensitivity (C&S) testing when indicated to identify the specific bacteria.

• Blood cultures: Performed if there are signs of a bloodstream infection, such as in patients with fever, weakened immune systems, a history of intravenous drug use, or implanted devices like shunts or catheters.

• Antinuclear antibody (ANA) test: To screen for systemic lupus erythematosus (SLE), an autoimmune disease.

• Renal biopsy: This involves taking a small sample of kidney tissue for microscopic examination. It is essential for a definitive diagnosis, especially in cases of primary kidney diseases. A renal biopsy is usually only considered in specific situations, such as:

  • Hepatitis B infection.

  • Cases of nephritis where the cause is unclear.

  • Infective endocarditis (infection of the heart valves).

  • Association with Henoch-Schonlein purpura (HSP), a condition causing inflammation of small blood vessels.

Management

1. Hospital admission is generally recommended for patients experiencing:

   • Complete absence of urine (anuria).

   • Nephrotic syndrome (a kidney disorder characterized by heavy protein loss).

   • Significant protein in the urine (massive proteinuria).

   • Significantly high blood pressure.

   • Pulmonary symptoms (indicating lung involvement).

2. Salt restriction (sodium restriction):

   • Salt should not be avoided during cooking and should not be added to food (salt-free diet).

   • If swelling (edema) is severe, a strict no-salt diet may be necessary.

   • Medications that are primarily eliminated by the kidneys should be used cautiously or avoided.

   • It’s important to note that the disease is usually self-limiting, and most patients recover without specific interventions.

3. Rest:

   • The patient should rest in bed in a warm and well-ventilated room during the acute phase.

   • Encouraging movement (ambulation) is helpful to reduce swelling and the risk of blood clots in the legs (deep vein thrombosis – DVT).

4. Dietary regulations (Diet regimen):

   • The amount of protein in the diet should be moderate, around 20 to 40 grams daily.

   • Ensuring enough calories from carbohydrates and fats helps to minimize the breakdown of protein for energy.

5. Fluids and electrolytes:

   • Closely monitor the patient for signs and symptoms of fluid overload.

   • Daily weighing of the patient is important.

   • Encourage adequate fluid intake (2-3 liters in 24 hours) to help increase urine output, unless otherwise indicated.

   • An intake and output chart must be maintained, and the urine should be tested daily for protein, red blood cells, and casts.

   • Electrolyte imbalances (such as low calcium, high potassium) and acidosis should be corrected if present.

   • Restrict fluids in patients with significant swelling.

   • Loop diuretics (medications that help the body get rid of excess fluid) are indicated for patients with nephrotic syndrome (about 4% of patients) or massive proteinuria.

6. Eradicate streptococcal causes:

   • Treat any underlying streptococcal infection with oral antibiotics.

   • Penicillin is the usual choice for patients without allergies, for example, phenoxymethyl penicillin 500mg four times a day (qid), or for children, 10–20 mg per dose. Alternatively, amoxicillin 500mg three times a day (tds), or for children, 15mg/kg per dose.

   • If the patient is allergic to penicillin, erythromycin can be given every 6 hours, or for children, 15mg/kg per dose.

7. Prophylactic treatment: Consider monthly penicillin injections or erythromycin to reduce the risk of recurrence, particularly in those with repeated infections.

8. Agents useful in treating hypertension: These include calcium channel blockers such as nifedipine and amlodipine, and nitroprusside sodium for severe cases.

9. Dialysis may be necessary in cases of:

   • Fluid overload that cannot be managed with diuretics.

   • Severe azotemia (very high levels of waste products in the blood).

   • Severe electrolyte abnormalities.

10. Pulmonary edema (fluid in the lungs) requires:

    • Aggressive use of diuretics.

    • Oxygen therapy.

    • Morphine to help with breathing and anxiety.

    • In severe cases, mechanical ventilation may be needed.

11. Hyperkalemia (high potassium levels) requires:

    • Restricting potassium intake orally and intravenously.

    • Using potassium-binding resins to help remove potassium from the body.

    • Nebulized salbutamol and glucose with insulin to temporarily shift potassium into cells.

    • Calcium infusion to protect the heart from the effects of high potassium.

Prognosis

The prognosis is generally less favorable with acute glomerulonephritis compared to nephrotic syndrome.

Nursing Diagnosis

1. Ineffective breathing pattern related to pulmonary edema or heart failure, as evidenced by shortness of breath.

2. Altered urinary elimination related to decreased bladder capacity or irritation secondary to infection, as evidenced by oliguria.

3. Excess fluid volume related to a decrease in regulatory mechanisms (renal failure), as evidenced by edema.

4. Risk for infection related to a decrease in the immunological defense.

5. Imbalanced nutrition less than body requirements related to anorexia, nausea, and vomiting.

6. Risk for impaired skin integrity related to edema and itching (pruritus).

7. Hyperthermia related to the ineffectiveness of thermoregulation secondary to infection, as evidenced by a thermometer reading above normal ranges.

Nursing Care Planning and Goals

Nursing care planning goals for a child with acute glomerulonephritis are:

• Excretion of excessive fluid through urination.

• Demonstration of behaviors that would help in excreting excessive fluids in the body.

• Improvement of distended abdominal girth (if present due to fluid).

• Improvement of respiratory rate to a normal range.

• Participation and demonstration of various ways to achieve effective tissue perfusion.

Nursing Interventions

• Activity: Bed rest should be maintained until the acute symptoms and visible blood in the urine (gross hematuria) have resolved.

• Prevent infection: Protect the child from chilling and contact with people who are sick.

• Monitor intake and output: Carefully track and record both fluid intake and urinary output, paying special attention to keeping the intake within prescribed limits.

• Monitor Blood Pressure: Check blood pressure regularly, using the same arm and a properly sized cuff.

• Monitor urine characteristics: Regularly test the urine for protein and blood using dipstick tests.

Evaluation

Goals are met as evidenced by:

• Excretion of excessive fluid through urination.

• Demonstration of behaviors that would help in excreting excessive fluids in the body.

• Improvement of distended abdominal girth.

• Improvement of respiratory rate.

• Participation and demonstration of various ways to achieve effective tissue perfusion.

Prevention

• Early treatment of throat and skin infections is crucial.

• Avoid overcrowding to minimize the spread of infections.

• Ensure adequate ventilation in dwellings.

Complications

• Renal failure (acute or chronic).

• Nephritic syndrome (a combination of glomerulonephritis features).

• Hypertensive encephalopathy (brain dysfunction due to very high blood pressure).

• Heart failure.

• Pulmonary edema (fluid buildup in the lungs).

Patients who present with features of both nephritic syndrome and acute glomerulonephritis are said to have nephritic nephritis, and the prognosis in these cases is less favorable.