Acute glomerulonephritis (AGN) is one of the most common kidney disorders in children, requiring careful observation and specialized nursing care. This condition occurs when the tiny filtering units in the kidneys called glomeruli become inflamed, impairing the kidneys’ ability to filter blood effectively. For pediatric nurses, understanding the pathophysiology, clinical manifestations, and management of AGN is essential for providing optimal care and preventing serious complications.
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What is acute glomerulonephritis?
Acute glomerulonephritis is a subset of renal diseases characterized by immune-mediated damage to the glomerular basement membrane, mesangium, or capillary endothelium. This damage leads to the classic triad of hematuria, proteinuria, and azotemia. The glomeruli, which are clusters of microscopic blood vessels acting as filters in the kidneys, become swollen and irritated due to inflammation. When this happens, waste products accumulate in the blood, and protein and red blood cells leak into the urine.
The most common form in children is post-streptococcal glomerulonephritis (PSGN), which develops as an immune response following infection with group A streptococcus bacteria. This typically occurs one to two weeks after a throat infection or up to three to six weeks after a skin infection like impetigo.
Pathophysiology and causes
AGN develops through an immune-complex-mediated mechanism. When a child gets a streptococcal infection, the body produces antibodies to fight it. However, these antibodies can form immune complexes that deposit in the glomerular tissue, triggering inflammation. Two main antigens contribute to this pathogenesis: nephritis-associated plasmin receptor (NAPlr) and streptococcal pyrogenic exotoxin B (SPeB). These antigens activate the complement system through the alternate pathway, causing aggregation in glomerular blood vessels.
The condition primarily affects children aged between 3 and 12 years, with peak occurrence around ages 5 to 7 years. Males are affected approximately twice as often as females. While the incidence has declined significantly in developed countries due to improved hygiene and antibiotic use, AGN remains a significant cause of hospitalization in developing regions.
Other causes of AGN
Besides streptococcal infections, AGN can result from several other conditions. Systemic immune diseases like lupus, Henoch-Schönlein purpura, and other vasculitides can trigger glomerular inflammation. Some cases may be associated with hepatitis B infection or other bacterial infections including Staphylococcus aureus.
Clinical manifestations
The classic presentation of AGN includes the triad of hematuria, edema, and hypertension. However, approximately 50% of children with PSGN are asymptomatic and discovered accidentally during routine urine analysis. When symptoms do appear, they typically manifest one to two weeks after a streptococcal throat infection.
Hematuria: Children often present with dark red or brown urine, described as tea-colored, cola-colored, or smoky. This occurs due to bleeding in the kidneys from damaged glomeruli. Gross hematuria is the most common presenting symptom, occurring in 30 to 50% of acute cases.
Edema: Swelling typically begins around the eyelids, especially noticeable when the child wakes up. It may extend to the face, ankles, abdomen, and other body parts as fluid accumulates due to impaired kidney function. This periorbital puffiness is often the first sign noticed by parents.
Hypertension: Hypertension is the most common initial complication, with approximately 64% of children presenting with elevated blood pressure. This occurs due to sodium and water retention from impaired kidney function.
Oliguria: Decreased urine output is common as the kidneys struggle to filter blood properly. Some children may experience less frequent urination despite adequate fluid intake.
Other symptoms: Children may also experience generalized weakness, fever, abdominal discomfort, malaise, and loss of appetite. Respiratory symptoms may occur if fluid accumulates in the lungs.
Diagnostic evaluation
Diagnosis of AGN involves thorough history-taking, physical examination, and laboratory investigations. Nurses should document any recent history of streptococcal infection, including sore throat or skin infections within the preceding weeks.
Urinalysis: The presence of red blood cell casts in urine is diagnostic of glomerulonephritis when present. Proteinuria and hematuria are nearly always evident in AGN.
Blood tests: Serum complement C3 levels are typically decreased in most children with PSGN due to consumption during the inflammatory process. Elevated blood urea nitrogen (BUN) and creatinine indicate impaired kidney function. A positive anti-streptolysin O (ASO) titer confirms recent streptococcal infection.
Throat culture: May be positive for group A beta-hemolytic streptococcus if infection is still present.
Additional tests: Kidney ultrasound may be performed to assess kidney size and rule out other conditions. Kidney biopsy is rarely needed but may be recommended if symptoms worsen or diagnosis is uncertain.
Medical management
Treatment of AGN is primarily supportive because there is no specific therapy for the kidney disease itself. By the time a child presents with symptoms, glomerular injury has already occurred and the healing process has begun. Management focuses on controlling symptoms and preventing complications.
Antibiotics: Penicillin is given to eradicate any remaining streptococcal bacteria and prevent spread to others. This does not reverse the kidney disease but eliminates the infectious source.
Antihypertensive agents: Diuretics such as thiazides or loop diuretics are first-line medications for managing hypertension and edema. Calcium channel blockers may be added for better blood pressure control. ACE inhibitors are typically avoided during the acute phase due to risk of worsening kidney function.
Dietary modifications: Sodium restriction helps prevent fluid retention, while protein intake may need limiting to reduce waste product accumulation. Potassium and phosphorus restrictions may also be necessary depending on kidney function.
Dialysis: In severe cases with significant renal impairment causing volume excess or dangerous electrolyte abnormalities, dialysis may be required temporarily.
Nursing assessment
Comprehensive nursing assessment is crucial for early detection of complications and effective management of AGN. Assessment should be systematic and ongoing throughout the child’s hospitalization.
Vital signs monitoring: Blood pressure should be measured regularly using the same arm and appropriately sized cuff. Blood pressures exceeding the 99th percentile for age, sex, and height require immediate attention, especially if accompanied by neurological symptoms.
Fluid balance: Strict monitoring of intake and output is essential. Daily weights at the same time each day provide the most accurate indicator of fluid status. Assess for peripheral edema, periorbital swelling, and signs of pulmonary congestion.
Urine characteristics: Note color, clarity, and amount of urine. Dark or cola-colored urine indicates ongoing hematuria. Collect specimens for urinalysis as ordered.
Neurological status: Monitor for headache, visual disturbances, altered consciousness, or seizures, which may indicate hypertensive encephalopathy.
Respiratory assessment: Auscultate lung sounds for crackles or decreased breath sounds that may indicate pulmonary edema from fluid overload.
Nursing interventions
Nursing care for children with AGN focuses on promoting recovery, preventing complications, and educating families.
Activity and rest: Bed rest should be maintained until acute symptoms and gross hematuria disappear. Rest reduces renal workload and allows the kidneys to heal. Gradually increase activity as the child’s condition improves.
Infection prevention: Protect the child from exposure to infections. Visitors with respiratory symptoms should be restricted. Good hand hygiene practices should be enforced by all caregivers.
Fluid and dietary management: Administer fluids within prescribed limits. Ensure compliance with sodium-restricted diet by working with dietary services to provide palatable options. Monitor for signs of fluid overload or dehydration.
Medication administration: Administer antibiotics, diuretics, and antihypertensive medications as prescribed. Monitor for therapeutic effects and adverse reactions. Educate parents about the importance of completing the full antibiotic course.
Psychosocial support: Hospitalization can be stressful for children and families. Provide age-appropriate explanations of procedures and treatments. Allow parents to participate in care when appropriate to reduce anxiety.
Potential complications
Serious complications during the acute phase include hypertensive emergency, congestive heart failure, encephalopathy, and pulmonary edema. These occur due to hypervolemia from impaired kidney function. Approximately 21% of children may experience hypertensive emergencies requiring intensive care.
Children with severe hypertension may develop neurological symptoms including seizures. Around 30 to 35% of children with AGN experience cerebral complications related to elevated blood pressure. Early recognition and prompt treatment are essential to prevent permanent damage.
Prognosis and follow-up
The prognosis for children with PSGN is excellent, with more than 90% making a full recovery. Most symptoms improve within one to two weeks, though small amounts of blood may persist in urine for several months.
Follow-up care includes monitoring blood pressure, kidney function tests, and urinalysis. Complement levels typically normalize within 8 to 12 weeks. Children should be monitored annually to screen for any persistent urinary abnormalities or hypertension, as a small percentage may develop chronic kidney issues later in life.
Family education
Educating families is a vital nursing responsibility. Parents should understand the importance of completing antibiotic therapy for streptococcal infections to prevent spread. They should be taught to recognize signs of recurrence, including changes in urine color, swelling, or decreased urine output.
Prevention of future streptococcal infections through good hygiene practices should be emphasized. Parents should be advised to seek prompt treatment for any sore throat or skin infections in their child. Follow-up appointments should be stressed to monitor long-term kidney health.
What do you think? How would you prioritize nursing interventions when caring for a child with both hypertension and significant edema from acute glomerulonephritis? What strategies would you use to help a young child adhere to dietary restrictions during hospitalization?
References
- https://www.ncbi.nlm.nih.gov/books/NBK560644/
- https://www.cdc.gov/group-a-strep/about/post-streptococcal-glomerulonephritis.html
- https://pmc.ncbi.nlm.nih.gov/articles/PMC9521512/
- https://www.ncbi.nlm.nih.gov/books/NBK538255/
- https://www.chop.edu/conditions-diseases/glomerulonephritis-children
- https://nyulangone.org/conditions/glomerulonephritis-in-children/diagnosis
- https://www.kidney.org/kidney-topics/post-infectious-glomerulonephritis-pign
- https://pmc.ncbi.nlm.nih.gov/articles/PMC3228372/
- https://emedicine.medscape.com/article/239278-treatment
- https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/post-streptococcal-glomerulonephritis.html
- https://www.stanfordchildrens.org/en/topic/default?id=glomerulonephritis-in-children-90-P03085
- https://nurseslabs.com/acute-glomerulonephritis/
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