Indiana Kramer is a 6 year old who has recently completed a course of penicillin for acute tonsillitis. She presents today with her mother. Indiana doesn't seem to have recovered from her tonsillitis. Her fever has settled, but she is lethargic and not eating much. This morning she told her mother that her urine was a different colour and dark. Her mother thinks that she might have an infection and has brought a sample into the surgery. Urinanalysis is positive for blood and protein.
Clinical features of acute glomerulonephritis (nephritic syndrome):
Acute presentation with these clinical features is seen most frequently in post-streptococcal glomerulonephritis and follows 7-14 days after a group A haemolytic strep throat infection and 3-6 weeks after streptococcal skin infection. It is hypothesized that streptococcal antigens deposit in glomeruli with activation of the complement system. Pathological appearance is of proliferation of mesangial and endothelial cells with neutrophil infiltration.
This is a high reading, at the upper limit of normal, for her age. However normal blood pressure for children varies with gender, age and height and a child should not be regarded as being hypertensive unless three recordings give levels above the 95th percentile for age and height. Range age 5 – 2 years 90-110. Normal upper limit at rest 4 – 7 years 115.
Approximate normal upper limit for pulse, respiratory rate and systolic blood pressure, at rest; resting measurements consistently above these values should arouse suspicion
| Age group | Pulse rate (beats/min) |
Respiratory rate (breaths/min) |
Systolic BP (mmHg) |
|---|---|---|---|
| 0-8 weeks | 160 | 50 | 70 |
| 2-12 months | 145 | 40 | 85 |
| 1-3 years | 130 | 30 | 100 |
| 4-7 years | 115 | 20 | 115 |
Laboratory urinalysis which would show red cell casts and dysmorphic red cells.
Elevation of serum urea, creatine and potassium concentrations. Mild normocytic normochronic anaemia is common due to haemodilution due to fluid overload. The results that would suggest post streptococcal GN would be elevated streptococcal markers: ASOT (antistreptolysin O titre) and antistreptococcal DNAase B (anti-Dnase B) are elevated in 90% of cases, can be associated with low serum levels of C3 and possibly C4.
Indiana should have oral penicillin for 10 days to eradicate any existing streptococcal infection, although this does not alter the natural history of the condition. Then management involves treatment of overload with diuretics and control of hypertension (mild with furosemide and fluid restriction, moderate to severe oral nifedipine or nitroprusside rarely parental hydralazine or nitroprusside). Bed rest if elevated blood pressure.
Increased glomerular cellularity restricts glomerular blood flow and therefore filtration is decreased this leads to:
The lack of availability of dialysis services can mean having to uproot families in order to obtain necessary medical care. Financial barriers as well as the time involve in travel can increase difficulty of keeping appointments. Can affect general well-being as well as finances. Relocating home and family may solve this access problem but is extremely disruptive, further hindering their quality of life.
While it may not be cost-efficient to distribute chronic care services, such as dialysis, more widely in rural areas there is an argument for doing so to overcome travel barriers.