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POST STREPTOCOCCAL
GLOMERULONEPHRITIS
PRAVEEN RK
NO: 75
DEFINITION
• Acute inflammation of renal glomerular parenchyma due to deposition of
immune complexes characterized by sudd...
ETIOLOGY
• PSGN follows infection of the throat or skin by certain
“nephritogenic” strains of group A β‐hemolytic streptoc...
• Epidemics of nephritis have been described in association with throat (serotypes
M1, M4, M25, M12) and skin (serotype M4...
• Throat infection: Winter or early spring
• Pyoderma : late summer or fall
• Overall risk of infection: 15%, regardless o...
PATHOGENESIS
• Trapping of circulating immune complexes in glomeruli
• Molecular mimicry between streptococcal antigens an...
PATHOLOGY
• GROSS
Kidney symmetrically enlarged
LIGHT MICROSCOPY
• Glomeruli enlarged and ischaemic
• Capillary loops narrowed – it make glomeruli appeared as bloodless
•...
IMMUNOFLUORESCENCE MICROSCOPY
• Immunofluorescence microscopy reveals a pattern of “lumpy‐bumpy”
deposits of immunoglobuli...
ELECTRON MICROSCOPY
• Electron microscopy, electron‐dense deposits, or “humps,” are
observed on the epithelial side of the...
CLINICAL FEATURES
• Abrupt onset
• Age 4 – 12 years, M>F
• Latent period : Throat infection : 1‐2 weeks
Skin infection : 3...
PROTEINURIA
• Mild to moderate but nephrotic range is rare
OLIGURIA
• Transient – 50%, Anuria rare
EDEMA : 85%
• Mild : periorbital or pedal
• Severe : hypertension, pleural effusion or ascites
• Adolescents : more likely...
HYPERTENSIVE EMERGENCY: 10%
• BP > 30% increased for age &sex
• Evidence of encephalopathy
• Heart failure or pulmonary ed...
ATYPICAL PRESENTATION
• Pulmonary edema
• Congestive cardiac failure
• Hypertensive encephalopathy
• Renal failure
• Nephr...
INVESTIGATIONS
URINE
• Dysmorphic or crenated RBC and RBC casts
• Moderate proteinuria ; 5‐10% nephrotic range (Lasts for ...
• ASO titres elevated 1‐5 weeks after infection in 80%, four fold rise,
• Return to normal after several months
• The best...
INVESTIGATIONS FOR ETIOLOGIC FACTORS
• Culture of organisms in throat or skin
• ASO titre - ↑ (only in throat infection)
•...
MANAGEMENT
PRINCIPLES
• Eliminate streptococcal infection with antibiotics
• Supportive therapy
• Diuretics and anti-hyper...
DIET
• The intake of sodium, potassium and fluids should be restricted until blood levels
of urea reduce and urine output ...
DIURETICS
• Oral FUROSEMIDE( 1- 3 mg /kg) – for edema
• IV FUROSEMIDE ( 2- 4 mg /kg) – pulmonary edema
HYPERTENSION
• Mild – restriction of salt and water
• Anti hypertensive agents – AMLODIPINE
NIFEDIPINE
DIURETICS
• Hyperte...
LVF
• Hypertension control
• IV furosemide as diuretics
• This will lead to improvement in LVF
• If no diuresis – dialysis...
PROLONGED OLIGURIA
• Dialysis
Severe renal failure
Hyperkalemia
Severe metabolic acidosis
Uremic pericarditis and encephal...
DAILY MONITORING
• Clinical : Edema, JVP, BP
Fluid intake and output
Weight
Respiratory status
Neurological status
ECG if ...
OUTCOME AND PROGNOSIS
• Excellent prognosis in childhood
• Edema and BP ↓ - 1 st week
• Gross hematuria and significant pr...
INDICATIONS‐ RENAL BIOPSY
• Nephrotic range proteinuria in acute
stage
• Normal serum complement
• Progressively increasin...
THANK YOU
Post streptococcal glomerulonephritis
Post streptococcal glomerulonephritis
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Post streptococcal glomerulonephritis

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Acute Glomerulonephritis

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Post streptococcal glomerulonephritis

  1. 1. POST STREPTOCOCCAL GLOMERULONEPHRITIS PRAVEEN RK NO: 75
  2. 2. DEFINITION • Acute inflammation of renal glomerular parenchyma due to deposition of immune complexes characterized by sudden onset of Oliguria Hematuria Hypertension Edema
  3. 3. ETIOLOGY • PSGN follows infection of the throat or skin by certain “nephritogenic” strains of group A β‐hemolytic streptococci • Usually occurs 7 – 14 days after pharyngitis 2 wks – 6 wks after skin infection
  4. 4. • Epidemics of nephritis have been described in association with throat (serotypes M1, M4, M25, M12) and skin (serotype M49) infections
  5. 5. • Throat infection: Winter or early spring • Pyoderma : late summer or fall • Overall risk of infection: 15%, regardless of site • Risk of infection after pyoderma: 25% • Asymptomatic carriers: 20%, may thus occur in absence of prodrome • Peak incidence in pre‐school children. Clinically apparent GN occurs in < 2% of children infected with strep infection RISK FACTORS
  6. 6. PATHOGENESIS • Trapping of circulating immune complexes in glomeruli • Molecular mimicry between streptococcal antigens and renal antigens (glomerular tissue acts as auto antigen reacts with circulating antibodies formed against strep antigens) • In situ immune complex formation against anti strep antibodies and glomeruli • Direct complement activation
  7. 7. PATHOLOGY • GROSS Kidney symmetrically enlarged
  8. 8. LIGHT MICROSCOPY • Glomeruli enlarged and ischaemic • Capillary loops narrowed – it make glomeruli appeared as bloodless • Diffuse proliferation of mesangial cells • Polymorphonuclear leukocyte infiltration • Crescents and interstitial inflammation in severe cases
  9. 9. IMMUNOFLUORESCENCE MICROSCOPY • Immunofluorescence microscopy reveals a pattern of “lumpy‐bumpy” deposits of immunoglobulin and complement on the glomerular basement membrane and in the mesangium.
  10. 10. ELECTRON MICROSCOPY • Electron microscopy, electron‐dense deposits, or “humps,” are observed on the epithelial side of the glomerular basement membrane
  11. 11. CLINICAL FEATURES • Abrupt onset • Age 4 – 12 years, M>F • Latent period : Throat infection : 1‐2 weeks Skin infection : 3‐6 weeks HEMATURIA • Smoky brown or Cola colored • Glomerular: dysmorphic RBC, casts in freshly spun urine
  12. 12. PROTEINURIA • Mild to moderate but nephrotic range is rare OLIGURIA • Transient – 50%, Anuria rare
  13. 13. EDEMA : 85% • Mild : periorbital or pedal • Severe : hypertension, pleural effusion or ascites • Adolescents : more likely face and legs HYPERTENSION: in 80% • Headache, Somnolence • Changes in mental status • Anorexia, Nausea , Convulsions
  14. 14. HYPERTENSIVE EMERGENCY: 10% • BP > 30% increased for age &sex • Evidence of encephalopathy • Heart failure or pulmonary edema AZOTEMIA : varying degrees CIRCULATORY CONGESTION : 20% • Dyspnoea, Orthopnoea • Cough, Tachycardia, Gallop rhythm • Basal crepitations, CCF, Pulmonary edema
  15. 15. ATYPICAL PRESENTATION • Pulmonary edema • Congestive cardiac failure • Hypertensive encephalopathy • Renal failure • Nephrotic syndrome
  16. 16. INVESTIGATIONS URINE • Dysmorphic or crenated RBC and RBC casts • Moderate proteinuria ; 5‐10% nephrotic range (Lasts for approximately 5 month) • Leukocyte or granular or hyaline casts BLOOD • Transient elevation of urea and creatinine • Low complement S.C3 in >90% ‐ in first 2 weeks(normalises in 6‐8 weeks) • Serum CH50 is commonly depressed, C4 is most often normal or mildly depresed in PSGN.
  17. 17. • ASO titres elevated 1‐5 weeks after infection in 80%, four fold rise, • Return to normal after several months • The best single antibody titer to document cutaneous streptococcal nfection is the antideoxyribonuclease B level Chest Xray may show pulmonary congestion, cardiomegaly Tubular function is preserved, or mildly reduced
  18. 18. INVESTIGATIONS FOR ETIOLOGIC FACTORS • Culture of organisms in throat or skin • ASO titre - ↑ (only in throat infection) • Single most specific test – Anti DNAase B ↑ (Skin infections)
  19. 19. MANAGEMENT PRINCIPLES • Eliminate streptococcal infection with antibiotics • Supportive therapy • Diuretics and anti-hypertensives to control BP and ECF volume
  20. 20. DIET • The intake of sodium, potassium and fluids should be restricted until blood levels of urea reduce and urine output increases
  21. 21. DIURETICS • Oral FUROSEMIDE( 1- 3 mg /kg) – for edema • IV FUROSEMIDE ( 2- 4 mg /kg) – pulmonary edema
  22. 22. HYPERTENSION • Mild – restriction of salt and water • Anti hypertensive agents – AMLODIPINE NIFEDIPINE DIURETICS • Hypertensive emergencies – IV NITROPRUSSIDE or LABETALOL
  23. 23. LVF • Hypertension control • IV furosemide as diuretics • This will lead to improvement in LVF • If no diuresis – dialysis initiated • Respiratory support – positive end expiratory pressure
  24. 24. PROLONGED OLIGURIA • Dialysis Severe renal failure Hyperkalemia Severe metabolic acidosis Uremic pericarditis and encephalopathy Intoxications- methanol,Li Fluid overload Life threatening electolyte disturbances
  25. 25. DAILY MONITORING • Clinical : Edema, JVP, BP Fluid intake and output Weight Respiratory status Neurological status ECG if hyperkalemic • Biochemical: Urine microscopy, Blood Urea, Creatinine, Electrolytes
  26. 26. OUTCOME AND PROGNOSIS • Excellent prognosis in childhood • Edema and BP ↓ - 1 st week • Gross hematuria and significant proteinuria – Disappear within 2 weeks • Hypertension subsides within 2-3 wks • Non streptococcal GN – Unpredictable outcome
  27. 27. INDICATIONS‐ RENAL BIOPSY • Nephrotic range proteinuria in acute stage • Normal serum complement • Progressively increasing S creatinine • Prolonged hypocomplementemia > 3 m • Ongoing macrohematuria • Long lasting proteinuria • Persistent azotemia • Associated symptoms of systemic disease • Persistent azotemia • Associated symptoms of systemic disease • Postinfectious GN and secondary causes • Hepatitis B infection • Shunt Nephritis • Infective endocarditis • Associated with HSP
  28. 28. THANK YOU
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