Paediatric Clinical Guidelines

Renal 6.4

December 2004

THE INVESTIGATION AND MANAGEMENT OF ACUTE GLOMERULONEPHRITIS IN CHILDREN

DATE:December 2004

REVIEW DATE:December 2007

AUTHOR:Dr JHC Evans

JOB TITLE:Consultant Paediatric Nephrologist

INFORMATION SOURCE:Forfar and Arneil’s 5th edition

Medicines for Children, RCPCH, 1999

CLINICAL PATTERN of Acute nephritic syndrome

  • Haematuria
  • Oliguria
  • Oedema
  • Hypertension
  • Proteinuria

Some patients may also have features of Nephrotic syndrome (see Policy 6.3)

Majority of cases are post-infectious, with group A -haemolytic streptococcus the most common causative agent. Other important causes include IgA nephropathy, HSP nephritis and lupus nephritis. Usually presents 1 – 2 weeks post URTI and sore throat. For comprehensive list of aetiologies see Forfar & Arneil.

DIAGNOSIS:

Urinalysis:Usually macroscopic haematuria

Variable proteinuria

Urine microscopy:Should be done on fresh urine

Dysmorphic red cells and casts (red cell,

haemogranular and granular)

In mild case casts may be found only in centrifuged urine

Throat swab

Blood:

FBC and platelets:Mild normochromic, normocytic anaemia common

Renal function tests:U&E, bicarb, creatinine, albumin,

calcium, phosphate, total protein

ASOTitre

Anti-DNAse B and Antihyaluronidase titres: should be done in

the absence of evidence of sore throat as ASOtitre may not rise after streptococcal skin infection

C3, C3d, C4:Usually low C3 normal C4

Autoantibody screen including ANA

Immunoglobulins

Renal USS

CXR:If hypertensive or fluid overloaded

In cases with evolving renal failure, nephrotic syndrome or clinical features suggestive of systemic vasculitis would recommend discussion with paediatric renal team. In these cases further investigations to consider:

General Viral titres plus Hep B and C, HIV, Hantavirus titres

ANCA, Anti GBM, Cryoglobulin titre

MANAGEMENT:

Most children will need admission initially because of the presence of fluid retention, oliguria, hypertension or worsening renal function.

INFECTION

10/7 Penicillin (Does not affect natural history but limits spread of nephritogenic strain)

Phenoxymethylpenicillin:< 1 yr62.5 mg qds

1 – 5 yr125 mg qds

6 – 12 yr250 mg qds

> 12 yr500 mg qds

HYPERTENSION (i.e. BP >95% centile)

  • Treat fluid overload (see below)
  • Do not use an ACE Inhibitor (may worsen renal function)
  • Refer to Hypertension policy 2.2 which also includes BP centile charts.

FLUID BALANCE

  • Fluid balance should be closely monitored.
  • All children should be weighed daily.
  • All patients should be on a no added salt diet.
  • If oliguric (<0.5 ml/kg/hr) will require fluid restriction to replacement of insensible losses (400 ml/m2/day) + previous days urine output.
  • If overloaded i.e. hypertensive, raised JVP, oedematous should give Frusemide 1 – 2 mg/kg up to twice daily, to induce a negative fluid balance.

CRITERIA FOR REFERAL TO PAEDIATRIC NEPHROLOGY

COMPLICATIONS IN THE ACUTE PHASE OF ILLNESS:

  • Hyperkalaemia
  • Uncontrolled hypertension
  • Fluid overload unresponsive to diuretics

ATYPICAL FEATURES SUCH AS:

  • Deteriorating renal function
  • Nephrotic syndrome
  • Features suggestive of systemic vasculitis
  • Normal C3
  • Low C4
  • Positive antinuclear antibodies
  • Low C3 at 3 months
  • Persistence of proteinuria at 6 weeks

INITIAL MANAGEMENT OF COMPLICATIONS

HYPERKALAEMIA

  • All treatments to decrease serum potassium are temporary measures, prior to dialysis.
  • See Hyperkalaemia policy 10.11 for treatment.

HYPOCALCAEMIA

  • If symptomatic:10% Calcium gluconate 0.3 ml/kg iv over 5 – 10 mins.
  • Under 5 years:Liquid calcium sandoz 0.5 ml/kg qds
  • Above 5 years:Consider oral calcium carbonate which will also reduce

phosphate levels (calcichew 1 tds before meals)

ACIDOSIS

  • Sodium bicarbonate can be given orally 2mmol/kg/dy in 4 divided doses.

SEIZURES

  • Treat electrolyte disturbance or hypertension.
  • Many anticonvulsants accumulate in renal failure. Benzodiazepines are the safest.

PROGNOSIS AND FOLLOW UP

  • 95% of patients with post streptococcal nephritis will make a complete recovery.

However a small proportion will develop rapidly progressive glomerulonephritis.

  • If renal function is satisfactory and improving and the patient is normotensive an early discharge should be possible.
  • Follow up should include a convalescent ASOTitre and repeat complement levels & biochemistry at 3 months to ensure they return to normal.
  • Microscopic haematuria may persist for 1 – 2 years.
  • Children can be discharged from long term follow up once urinalysis, BP and creatinine are all normal.

Contact Numbers

Consultant Paediatric Nephrologist on-call / Via CityHospital switchboard
Paediatric Nephrology SpR / 46458 (Lambley Ward) or bleep via CityHospital switchboard
AUDIT POINTS
  1. Are investigations undertaken as per guidelines?
  2. Are referrals made to paediatric nephrology appropriate and at correct time?

PAEDIATRIC CLINICAL GUIDELINES

ISSUE:VERSION: FINAL

Title: THE INVESTIGATION AND MANAGEMENT OF ACUTE GLOMERULONEPHRITIS IN CHILDREN

Author: DrMT Christian

Job Title:Consultant Paediatric Nephrologist

First Issued:Date Revised: December 2004 Review Date: November 2007

Document Derivation:Consultation Process:

ReferencesConsultant Paediatric Nephrologists

Included in documentPaediatric Pharmacist

Cross town Paediatric Policy Group

Ratified By:Paediatric Protocols Committee

Chaired By:

Consultant with Responsibility: Dr Stephanie Smith

Distribution:All wards QMC and CHN

Training issues: included in the Induction Programme

Audit: included in the document

This guideline has been registered with Nottingham City Hospital NHS Trust and QMC Clinical Guidelines Committee. However, clinical guidelines are ’guidelines’ only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

MANUAL AMENDMENTS RECORD
(Please complete when making any hand-written changes/ amendments to protocol and not processed through protocol committee)
Date / Author / Description
16/12/04 / Martin Christian /
  1. Additional sentence to first paragraph on causes of acute nephritis.
  2. Hypocalcaemia. Change <5’s to calcium sandoz from calcium carbonate (agreed at committee)
  3. Change in contact details to state consultant paediatric nephrologist on-call

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