Poststreptococcal glomerulonephritis: diagnosis and treatment

Typically, dead bacteria and antibodies are eliminated from the body without problems. However, in the case of post-streptococcal glomerulonephritis, they become trapped in the renal glomeruli, which leads to slow filtration of the kidneys, the development of local intravascular coagulation and microthrombosis.

The likelihood of developing post-streptococcal infection in women during pregnancy is negligible.

OPSG - manifestations of the disease

Acute post-streptococcal glomerulonephritis in children is directly associated with:

• tonsillitis in acute or chronic form;
• inflammation of the maxillary sinuses;
• scarlet fever;
• infectious inflammation of the respiratory tract.

In rare cases, this type of disease can occur against the background of purulent-necrotic processes in the bone marrow, purulent skin lesions and otitis media with a purulent etiology.

Acute form

This disease is characterized by inflammation of the renal glomeruli on both sides and develops against the background of streptococcal infection. It is typical for boys and young people aged 14 to 35 years. Acute post-streptococcal glomerulonephritis is often recorded in childhood, at 6-10 years of age. It is directly associated with possible hypothermia. The disease is more common in regions with high humidity.

The development of pathology occurs in 35 cases per 1000 population. During the spring-winter cold season, the inflammatory process in the urinary organs is provoked by acute respiratory viral infections, and in the summer and autumn, pustular inflammation appears on the surface of the skin.

Condition of kidney tissue during OPSH - under a microscope

Reasons for development

Before understanding the main etiological factor in the occurrence of the disease, it is necessary to understand that in most cases, post-streptococcal glomerulonephritis occurs in children or adolescence, and boys are affected 1.5–2 times more often than girls. Less commonly, the poststreptococcal form develops during pregnancy.

Acute post-streptococcal glomerulonephritis in children occurs after suffering a corresponding streptococcal infection, namely:

• acute and chronic tonsillitis;
• scarlet fever, sinusitis;
• rhinitis;
• other infectious diseases of the upper respiratory tract.

Quite rarely, this syndrome complex can occur after osteomyelitis, pyoderma and purulent otitis.

Acute glomerulonephritis of the post-streptococcal form occurs due to contact of the human body with beta-hemolytic streptococcus of group A or strain No. 12, which is confirmed by immunological research methods.

Origin

The type of post-streptococcal glomerulonephritis described above often occurs due to streptococci belonging to group A entering the body. Subsequently, the body begins to actively produce antibodies that interact with antigens. These types of pathological processes lead to the appearance of specific immune complexes that affect the parenchymal tissue of the kidneys, leading to further damage and disruption of the structure of the renal units - nephrons.

Scheme of development of OPSG from tonsillitis and impetigo

Initially, the infection develops in the form of an immune complex pathology, but then begins to take the form of an autoantibody disease. At this stage, allergies begin to develop. Patients need to remember that this type of infectious disease tends to regress. Therefore, constant monitoring by a specialist and monitoring of the course of infectious processes in the body is necessary. In addition, it is necessary to organize proper prevention.

Prognosis and prevention

If the patient does not receive timely treatment, the acute form of glomerulonephritis becomes chronic, which will inevitably lead to the development of renal failure and death.

As a preventive measure it is recommended:

• avoid hypothermia;
• timely sanitation of the upper respiratory tract in case of inflammation of the latter;
• adequate treatment of tonsillitis, otitis and pharyngitis;
• strengthening the general condition of a person through hardening.

Treatment and prevention of acute post-streptococcal glomerulonephritis in children requires close attention of both the patient and the specialist. At the same time, to prevent life-threatening complications, patients with the post-streptococcal form must be constantly under the supervision of the attending physician.

Symptoms

For 7-14 days the patient will not experience any pronounced symptoms. And then the first renal or extrarenal symptoms will begin to appear. These include:

• changes in blood pressure;
• the occurrence of swelling on the body;
• disturbance in the cardiovascular system;
• the appearance of blood in the excreted urine;
• headache;
• pain in the lumbar region;
• decrease in the amount of urine excreted;
• the appearance of protein in the urine.

In the initial stage of the disease, it is imperative to visit a specialist and carry out the necessary diagnostic measures, as well as appropriate therapy.

ACUTE POST-STREPTOCOCCAL GLOMERULONEPHRITIS. OSGN

Therapy for patients with OSGN is carried out in a hospital; it should be extremely gentle. In addition to the regimen, diet, anti-inflammatory, including antibacterial therapy, basic therapy may include diuretics, drugs aimed at improving renal blood flow, eliminating or limiting intravascular thrombus formation in the kidneys.

Mode. During bed rest, the patient's entire body should be kept evenly warm. This improves blood circulation and relieves vascular spasms: more blood enters the kidneys, which leads to improved filtration in the glomeruli and increased diuresis. When diuresis is restored and extrarenal symptoms disappear, i.e. edema disappears, blood pressure decreases, and when examining urine, hematuria does not exceed 10-20 red blood cells in the field of view and albuminuria is no more than 1‰, the child can be transferred to semi-bed rest. However, the patient must be given heat to the lower back, i.e., he must wear a “quilted jacket” on this area. You should pay attention to the fact that when expanding the regimen, the patient constantly wears woolen socks, because cooling the feet is one of the factors contributing to the exacerbation of tonsillopharyngeal infection. Prolonged bed rest is not advisable. In the presence of cardiovascular disorders, it is useful to position the patient in a chair with his legs down - this reduces the load on the heart due to the deposition of blood in the inferior vena cava system. Typically, the duration of bed rest is 2-3 weeks. By the 5-6th week, the regimen is gradually brought to the ward level.

Diet. The most important thing in a diet for OSGN is limiting salt and water. Salt is strictly limited. At the height of the disease, in the presence of oliguria and hypertension, food is prepared without adding salt. Only in the 4-5th week, when oliguria disappears, blood pressure normalizes and swelling disappears, the patient is given 0.5 g of table salt per day to add salt to food, and by the 8th week - up to 1.5 g per day . Next, the amount of salt is gradually increased, but the maximum amount of table salt for 1-2 years should not exceed the norm of 50 mg/kg per day (food should be slightly under-salted).

The daily amount of fluid at the height of the illness should be equal to yesterday's diuresis, and in the absence of information about it - about 15 ml/kg (400 ml/m 2

) - insensible water loss per day.

Recently, great importance has been attached to significantly limiting the protein content in the diet of patients with OSGN. However, it has been established that this is only necessary for patients with azotemia. In these cases, on the first day after admission, a sugar-fruit day is prescribed at the rate of 14-12 g of carbohydrates per 1 kg of body weight, but not more than 300-400 g per day: carbohydrates from sugar, from pears, apples (pears and apples on average contain about 80-86% water; carbohydrates in pears - 10-18 g, in apples: Antonovka - 6 g, Jonathan - 12-16 g per 100 g of product) and due to jam and honey. Cranberry and lemon juices are beneficial. Product water is taken into account when calculating the total amount of liquid. It is important to ensure that the child eats the food offered, because fasting promotes catabolism and increased azotemia. If a child does not eat well what is prescribed on a sugar-fruit day, then he is given rice or semolina pudding or buns. Following this diet, an achloride, alkalitic diet is prescribed with protein and fluid restrictions to 0.5-1 g/kg per day. Rice or rice and potato dishes are recommended. Rice is cooked in milk. If the child does not eat well, then the food set may also include vegetables (carrots, cabbage, pumpkin, etc.), berries (lingonberries, cranberries, blueberries, blackberries, etc.), cereals, sugar, marmalade, marshmallows, vegetable oil, salt-free bread, i.e. almost only vegetable proteins. Table No. 3c (No. 7c according to Pevzner) meets these requirements, which can be used for low azotemia and instead of a sugar-fruit day. However, such poor nutrition cannot be prescribed to a child for a long time, as well as complete starvation. By the 3-5th day from the onset of the disease, you need to gradually expand the diet (1-1.5 g/kg of protein, i.e. table No. 3b or No. 7b according to Pevzner), introducing complete proteins, primarily through dairy products. By the 7-10th day, with a smooth course of acute nephritis, the amount of protein is adjusted to the physiological norm (2.5 g/kg - table No. 3a, i.e. No. 7 according to Pevzner). The expansion of nutrition is carried out gradually: first, eggs, wheat bread are introduced into the diet, then fish, cottage cheese, and only after that the patient is given meat and table salt for adding salt.

Table 107 shows the composition of diets for patients with OSGN.

In the first days of the disease, there is a danger of hyperkalemia, therefore, during the oliguric phase, the diet should be not only achloride, but also hypopotassium. During this period, fruits and vegetables rich in potassium are not prescribed, but when polyuria appears, the loss of salts can be so significant that there is a danger of developing hypokalemia, therefore, with normal diuresis, and especially during polyuria, the diet should be enriched with potassium (raisins, prunes, watermelons , oranges, bananas, potatoes, dried fruits, etc.). During the period of polyuria, especially against the background of a salt-free diet, hypochloremia (the danger of hypochloremic azotemia!) and hyponatremia (with a plasma sodium level of less than 120 mmol/l there is a danger of intracellular hyperhydration), hypomagnesemia, and hypocalcemia may occur.

The duration of the child's stay on the diet of table No. 3a is at least a month, and then it is advisable to transfer him to table No. 5a (this diet should be followed for 5 years).

During the oliguric period of the disease, it is especially important to monitor bowel function,

since during constipation, rotting products, absorbed through the intestinal wall, are not neutralized by the liver (its antitoxic function in this disease is reduced), enter the blood and increase intoxication. Taking this into account, cleansing enemas are done. With significant impairment of kidney function, nitrogen metabolism products are released through the mucous membrane of the stomach and intestines. To remove them more completely, you can rinse the stomach with a 2% solution of sodium bicarbonate.

Vitamin therapy. Vitamins B1, B2, C, and rutin are prescribed orally in usual therapeutic doses. Courses of vitamins B6, A, E are shown.

Antibiotic therapy is prescribed upon admission to the hospital for all patients with OSGN. An antibiotic (semi-synthetic penicillins, erythromycin or others) is prescribed in average therapeutic doses for 8-10 days, then a week-long break is taken and antibiotic therapy is administered again for 8-10 days. In the presence of chronic foci of infection or intercurrent diseases, it is also more advisable to use cyclic prescription of antibiotics (3-4 cycles). It is necessary to remember about the possibility of an allergic reaction to antibiotics (especially to penicillin!), and to identify it in the child anamnestiically and clinically. You should not resort to nephrotoxic antibiotics (aminoglycosides, methicillin, tetracycline, 1st generation cephalosporins, etc.).

Sanitation of foci of chronic infection (dental caries, cholecystitis, chronic tonsillitis, adenoiditis, etc.) is carried out without fail, but conservatively (physiotherapy, herbal medicine, rinsing, drainage, etc.). Removal of tonsils in the presence of decompensated chronic tonsillitis that is not amenable to conservative therapy is carried out no earlier than 6-12 months from the onset of the disease. After tonsillectomy, a course of antihistamines and antibiotics is indicated.

Diet therapy, regimen, and antibiotic therapy are practically the only treatment prescribed for all patients

. Large doses of vitamins C, B1, B12, rutin (previously widely recommended) are not currently used, because allergic reactions to these drugs are possible, they can stimulate the immunopathological process, intravascular coagulation. The above applies to calcium supplements. We especially emphasize that epsilon-aminocaproic acid, rutin, vitamin C in large doses, and calcium supplements stimulate intravascular blood coagulation and are therefore contraindicated in patients with acute hypertension. The wait-and-see tactics of drug therapy for ASGN is determined by the fact that specific treatment for it has not yet been developed, and the disease, as a rule, undergoes reverse development against the background of the treatment described above.

Pathogenetic therapy includes measures to improve renal blood flow

. regimen, electrophoresis with 1% nicotinic acid or heparin and intravenous infusions of aminophylline or theophylline, trental. This treatment produces a diuretic and antiplatelet effect. The combination of electrophoresis with nicotinic acid and the administration of xanthine drugs is indicated for severe oliguria and edematous syndrome. Eufillin is prescribed intravenously drip in glucose solution at a rate of about 2 mg/kg 3 times a day or intramuscularly, orally. Trental is a xanthine drug, produced in ampoules (5 ml of 2% solution) or dragees (100 mg), used intravenously or orally at a dose of 5 mg/kg 3 times a day. Dipyridamole (Curantyl) is prescribed in a daily dose of 5 mg/kg in 3 doses orally. Of course, the patient is prescribed only one of the antiplatelet agents. The effectiveness of prescribing antiplatelet agents for ASGN, as well as physiotherapy, has not been proven in randomized clinical trials. The same applies to the advisability of prescribing heparin. Almost all foreign clinics do not use these treatment methods for ASGN.

Diuretics are prescribed only to patients with severe edema and hypertension syndrome. For moderate edema, it is sufficient to use electrophoresis with nicotinic acid on the kidney area or aminophylline, trental. Usually they resort to Lasix (furosemide), administered intramuscularly or intravenously (single dose 1-1.5-2 mg/kg), in combination with hypothiazide (single dose 0.5-1 mg/kg orally along with furosemide) or amiloride (for schoolchildren 5 mg orally), prescribed 2 hours before taking furosemide. These combinations of drugs, acting on various parts of the nephron, increase the natriuretic and diuretic effect. The combination of furosemide and amiloride has a potassium-sparing effect. The duration of the effect of the drugs is 3-4 hours, but due to the fact that patients with diffuse glomerulonephritis have nocturia, they are not given diuretics in the evening. You can also use the following regimen for prescribing diuretics: 8 hours - furosemide, 10 hours - hypothiazide or triampur, and at 16 hours - veroshpiron. More often, diuretics are given to children with NS. When diuretics are prescribed, a lot of potassium and calcium are lost in the urine, and therefore these drugs must be prescribed at the same time.

Potassium-sparing diuretics should not be prescribed for hyperkalemia. Hypothiazide is also less effective for oliguria due to low filtration.

Antihypertensive drugs are prescribed only for severe and persistent hypertension, since usually moderate hypertension goes away with diet and diuretics. To reduce blood pressure in patients with acute hypertension, papaverine with dibazole is used either intramuscularly (in acute hypertensive crisis - 1% and 0.5% solution, 0.1 ml/kg each, respectively), or orally in the form of papazole (single dose for preschool and primary school age - and for older schoolchildren - tablets), reserpine (single dose 0.07 mg/kg, but not more than 2 mg) or methyldopa - dopegit (5-10 mg/kg orally, gradually increasing the single dose), adelfan , hemiton, captopril (angiotensinase drug). Antihypertensive drugs are given 2-3 times a day.

For eclampsia, emergency care is provided as follows: Lasix (2 mg/kg) is administered intravenously, papaverine with dibazole is administered intramuscularly, convulsions are relieved with diazepam (Sibazon, Seduxen, Valium) - 0.3-0.5 mg/kg intramuscularly (magnesium preparations are not shown).

Dispensary observation

All children after hospital should be admitted to a local sanatorium and then under the dispensary observation of a clinic. For the first 3 months, the local doctor examines the child every 10-14 days, measures blood pressure and does a urine test, for the next 9 months he does the same, but once a month, and for the next 2 years - once a quarter. In addition, a urine test is required for any intercurrent illness. In addition to routine monitoring of children who have suffered from acute respiratory syndrome, their chronic foci of infection are sanitized in the clinic (if this was not done in the hospital). A medical exemption from vaccinations is given for a period of up to 1 year. Physical activity during early convalescence should be limited.

Mild catarrh of the upper respiratory tract can often lead to a serious deterioration of renal disease, therefore, from the first days of the onset of an acute disease, antibiotic therapy should be carried out and after the end of the acute period of the disease, after 10 days, a blood test and a double urine test should be performed with an interval of 2-3 days. Home regime - at least 2 weeks.

If within 5 years after undergoing ASGN the child did not have any pathological changes and a comprehensive functional study of the kidneys in the hospital also did not reveal any deviations from the norm, then he can be considered recovered and removed from the dispensary register.

Forecast

When proven, OSGN is usually favorable. About 90-95% of children who survive the acute period recover. In 1-2% of patients, OSNG transforms into rapidly progressive GN. Chronic nephritis develops in 3-5% of children who become ill with OSGN in preschool age, and in 12-15% of children who become ill in high school age. Exacerbations and repeated attacks of OSGN are not typical, but they can happen.

Prevention

Early diagnosis and mandatory antibacterial treatment (penicillin, macrolides, semisynthetic penicillins) of all diseases of streptococcal etiology is an important link in the prevention of ASGN. The course of antibiotics must be at least 10 days. Mandatory urine analysis in the middle to the end of the 2nd week of illness for scarlet fever, sore throat and other diseases of streptococcal etiology contributes to early detection and hence a smoother course of ASGN. Contact children and family members of a patient diagnosed with severe acute streptococcal infection should receive treatment with penicillin or erythromycin.

Source: https://www.med2000.ru/mps/shabanov12.htm

Diagnostic methods

After visiting a specialist, who must take an anamnesis and do a visual examination, various types of laboratory tests are prescribed. Diagnostic methods include:

• general and biochemical blood test;
• general urine analysis;
• ultrasound examination of the kidneys;
• radiography;
• magnetic resonance imaging of the kidney structure;
• measurement of urination rate.

Urinalysis - diagnosis of OPSH

If the amount of urine output is reduced, urine laboratory tests may show increased amounts of creatinine and urea. This directly indicates that renal failure is developing. Using the ultrasound method, differential type disorders are detected, as well as kidney enlargement, which is caused by a violation of the outflow of urine.

In some cases, a medical council consisting of dentists, ophthalmologists and otolaryngologists may be assembled. This is necessary in order to identify possible concomitant diseases, such as the presence of dental caries, retinal vascular angiopathy and others.

Therapy

Treatment of acute post-streptococcal glomerulonephritis begins primarily with identifying the carrier of this microorganism: relatives or people around him. The next stage of therapy will be the reduction and constant regulation of blood pressure, which is achieved by prescribing antihypertensive drugs of various classes (calcium channel blockers, ACE inhibitors, beta blockers, diuretics). Treatment of this pathology should go in parallel with the correction of water-salt balance and reduction of swelling of tissues and organs.

With an accurate diagnosis of post-streptococcal glomerulonephritis, antibacterial therapy is mandatory, aimed at stopping the development of infection in the body, by prescribing bacteriostatic drugs, but not bactericidal ones. This is explained by the fact that bacteriostatics stop the replication of streptococcus, but do not kill it, otherwise the decay products of these microbes will begin to have a detrimental effect on the body, the latter will respond to them with a violent allergic reaction.

Treatment of acute post-streptococcal glomerulonephritis also includes suppression of the human immune system by administering large doses of steroid hormones (prednisolone, dexamethasone, adrenaline, hydrocortisone). This is done to reduce the circulation of immune complexes in the blood, which leads to the beginning of regeneration processes.

Don't forget about dietary treatment. The diet for acute post-streptococcal glomerulonephritis includes table No. 7, characterized by a small amount of animal protein and meat, as well as a high content of plant foods. Salt at this table is indicated in minimal doses.

Treatment and its types

Treatment of post-streptococcal glomerulonephritis is prescribed after the pathogen has been identified and it has been determined which of the patient’s relatives could have become infected. Monitor blood pressure changes and prescribe antihypertensive drugs.

A strict correction of the water-salt balance is carried out to reduce swelling in the tissues and internal organs.

Poststreptococcal glomerulonephritis is associated with a bacterial infection, so antibiotic therapy is prescribed. The most commonly used drugs are the penicillin group, such as phenoxymethylpenicillin and erythromycin. The use of these medications is indicated for tonsillitis or pharyngitis, as well as pustular skin infections.

The use of steroid hormonal drugs is practiced, such as:

• prednisolone;
• dexamethasone;
• adrenalin;
• hydrocortisone.

These measures are necessary to suppress the body's immune system response.

Treatment regimen for OPSH with antibiotics

An important stage in the treatment of an acute disease is following a special diet. It is based on reducing the amount of animal protein consumed and introducing large amounts of plant foods into the diet. Avoid salt consumption. It is also advisable to avoid fried, fatty and smoked foods.

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Alexey Portnov, medical editor Last revised: 06/24/2018

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Acute post-streptococcal glomerulonephritis (acute glomerulonephritis, acute nephritis, post-infectious glomerulonephritis) is an immunocomplex disease with diffuse damage to the kidneys, mainly the glomeruli, occurring 10-14 days after streptococcal infection (sore throat, impetigo, scarlet fever, pyoderma, etc.) and characterized by nephritic syndrome.