Question.Describe briefly Acute Glomerulonephritis.
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Write short note on acute glomerulonephritis.
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Write briefl on clinical features and management of acute glomerulonephritis.
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Write in brief sign, symptom and treatment of acute glomerulonephritis
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Discuss etiology, clinical features, investigations and treatment of acute glomerulonephritis.
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Describe briefl the clinical features and management of acute glomerulonephritis.
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Givedefiition,etiology,sign,symptoms,investigations and treatment of nephritic syndrome.
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Write etiology, clinical features, investigations and treatment of nephritic syndrome.
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Write Nephritic Syndrome under the following headings:
- Nephritic Syndrome Causes
- Nephritic Syndrome Clinical features
- Nephritic Syndrome Investigations
- Nephritic Syndrome Treatment
Answer.
Acute glomerulonephritis involves mainly the glomeruli and to lesser extent the renal tubules by an acute transient inflmmatory process which manifests clinically by acute reduction in glomerular fitration rate, rapid renal failure, proteinuria and salt and water retention.
Acute glomerulonephritis is also known as acute nephritic syndrome or nephritic syndrome.
Nephritic syndrome is characterized by oliguria,hematuria, proteinuria, edema, hypertension and acute renal failure.
Nephritic Syndrome Etiology
1. Infectious disease:
1. Poststreptococcal glomerulonephritis
2. Nonstreptococcal postinfectious glomerulonephritis
- Bacterial: Infective endocarditis, sepsis, Pneumococcal pneumonia, typhoid fever, secondary syphilis, meningococcemia
- Viral: Hepatitis B, infectious mononucleosis,mumps, measles, varicella, vaccinia, echovirus and coxsackievirus
- Parasitic: Malaria, toxoplasmosis
2. Multisystem disease:
- Systemic lupus erythematosus
- Vasculitis
- HenochSchönlein purpura
- Goodpasture’s syndrome
3. Primary glomerular disease:
- Mesangiocapillary glomerulonephritis
- Mesangial proliferative glomerulonephritis
4. Miscellaneous:
- Gullain-Barré syndrome
- Irradiation of Wilm’s tumor
- DiphtheriaPertussisTetanus (DPT) vaccine
- Serum sickness.
- IgA nephropathy
Read And Learn More: General Medicine Question And Answers
Clinical Features Nephritic Syndrome
Nephritic Syndrome Symptoms
- Patient complains to puffiss over the face and edema over the feet in early hours of morning.
- In some cases, headache, vomiting and abdominal pain is present.
Nephritic Syndrome Signs
- Generalized anasarca is present. It is more over face.
- Oligouria is present.
- Proteinuria is present. It is less than 1 g/day.
- Hypertension is present since there is retention of salt and water.
- Hematuria is present.
- Presence of circulatory congestion.
- Occurrence of circulatory congestion due to capillaritis,increased cardiac output and short circulation time.
2. Complications Nephritic Syndrome
- Hypertensive encephalopathy
- Acute left heart failure
- Noncardiogenic pulmonary edema
- Uremia
Management Nephritic Syndrome
- Bed rest: Patient should be hospitalized and rest is given till illness is resolved.
In mild cases, bed rest is given for 3 weeks and in severe cases for 3 months. - Fluid restriction: Avoid flid overload. For fist 24 hours only 500 mL of water or glucose or barley water should be given.
If volume of urine in 24 hours is less than 400 mL teart for acute renal failure and if it is more than 400 mL limit intake of flid to 500 mL + a volume equal to that passed in preceding 24 hours.
Fruit juices rich with potassium are given with caution. - Diet: Restrict dietary protein and restrict sodium and potassium intake. Monitor potassium and sodium.
- Hypertension: Moderatetosevere hypertension is controlled by hydralazine, betablockers such as atenolol or calcium channel blockers or ACE inhibitors.
Salt restriction should be done. - Antibiotics: Injection benzathine penicillin 500,000 units IM 6 hourly for 7 days.
- Diuretics: It is not indicated unless there is acute LVF or pulmonary edema is present.
Frusemide 40 mg IV daily for few days, followed by oral substitution till diuretic phase is induced. - In patients with progressive renal failure or if fluid overload is present, dialysis may have to be employed.
Causes Nephrotic Syndrome
1. Primary glomerular diseases:
- Minimal change nephropathy.
- Mesangioproliferative glomerulonephritis.
- Membranous nephropathy
- Focal and segmental glomerulosclerosis.
- Crescentic glomerulonephritis
2. Idiopathic
3. Secondary to other diseases:
- Infections: Malaria, hepatitis B, herpes zoster,
streptococcal and staphylococcal infections syphilis,leprosy, schistosomiasis. - Drugs: NSAIDs, heavy metals such as gold, anti –convulsants, penicillamine, ACEinhibitors, heroin,rifampicin, tolbutamide and probenecid.
- Malignancy: Hodgkin’s disease and other lymphomas.
- Systemic diseases: Diabetes mellitus, amyloidosis,systemic lupus erythematosus, HenochSchonlein purpura, cryoglobulinemia, polyarteritis nodosa.
- Familial disorders: Congenital (neonatal) nephrotic syndrome, Alport’s syndrome, Fabry’s disease
- Miscellaneous conditions: Reflx nephropathy, renal vein thrombosis, toxemia of pregnancy, allergic reactions to insect bites, pollens and vaccines, renal artery stenosis.
Clinical Features Nephrotic Syndrome
- Age and sex: Nephrotic syndrome is two to three times more common in childhood with peak incidence at 2–3 years.
In this age group, there is a male: female ratio of 2.5 : 1, in adults, sex incidence is equal. - Edema: It is peripheral involving the limbs, particularly lower limbs.
In children, edema may be more obvious in the face and abdomen. Usually, massive generalized anasarca, the patient almost weighing double his true weight. Intense edema of the scrotum or vulva may occur.
There may be bilateral hydrothorax. Edema may persist for many weeks or months.
Spontaneous subsidence with diuresis (nephrotic crisis) may occur, to be followed again by increase of edema. - Gastrointestinal symptoms: Anorexia causes severe malnutrition, Diarrhea and vomiting due to edema of intestinal wall.
General symptoms: Prolonged protein loss causes anorexia,lethargy, tiredness, frequent infections and muscle wasting.
Dyspnoea may occur, if there is flid in the pleural cavity. - Blood pressure: There may be periods of hypertension; ultimately with development of chronic nephritis permanent hypertension may develop.
Investigations
Urine examination
- Oliguria while edema is forming, dieresis or normal amount of urine during period of subsidence of edema.
- Proteinuria: It is massive, usually more than 5 g/day though variable from time to time; urine becomes almost solid on boiling.
Daily loss of protein may be 20–50 g. - 24 hour urine shows excretion of albumin or protein more than 3.5 g/day.
- Red blood cells are absent or few are seen
- Casts: Fatt casts, tubular cells, oval fat bodies, doubly refractile bodies are seen
Blood examination: Nephrotic Syndrome
- Anemia: It is slight normochromic.
- Hypoalbuminemia: Serum albumin usually less than 3 g/100 mL. Total serum globulin concentration frequently lowered with often elevation of α2 and β-globulins.
- Serum lipids show increase in LDL levels and cholesterol.
- ESR is raised due to hyperfirinogenemia.
- Serum complement level: Serum complement C3 and C4
- levels get reduced.
- Other biochemical tests, i.e. blood urea, serum creatinine, creatinine clearance and electrolytes are normal.
- Ultrasound of abdomen: It can show normal small or large kidneys which depends on the underlying cause.
Amyloid and diabetic kidneys are large while kidney in glomerulonephritis is small. - Renal biopsy: It is normal on light microscopy but electron
microscopy shows typical abnormalities (effcement of epithelial cell foot processes).
Treatment Nephrotic Syndrome
- Edema: Advice patient to take low sodium diet, i.e. 1–2 g/day. In mild edema thiazide induce gentle dieresis.
In moderate edema, frusemide in doses of 80–120 mg/ day or torsemide 20–40 mg/day is given.
In patients with severe edema frusemide 20–40 mg/day is combined with spironolactone 100–200 mg/day for complete resorption of sodium throughout the nephron. - Corticosteroids: Produce rapid and complete remission with clearing of proteinuria in 90% cases. Dosage is
- Prednisolone 1 mg/kg/day, maximum 80 mg/ day.
Remission usually occurs between days 7 and 14, though some patients need up to 16 weeks therapy to achieve complete remission.
Prednisolone dose is reduced to 0.5 mg/kg/day and then tapered slowly.
An attmpt to stop treatment should be made after 8 weeks.
In patients who relapse, course of prednisolone should be repeated. - Immunosuppressive drugs: In steroidresistant patients, or in those in whom remission can only be maintained by heavy doses of steroids, cyclophosphamide 1.5–2 mg/kg/ day for 8–12 weeks with concomitant prednisolone 7.5–15mg/day.
- Levamisole: In corticosteroid dependent children 2.5 mg/kg to maximum 150 mg on alternate days is useful in maintenance of remission.
- Antibiotics: Aggressive antibiotic therapy is given in nephrotic syndrome as chances of sepsis are always present. Mainly cephalhexins are given.
Glomerulonephritis
Involvement of glomeruli in the kidney either by the process of inflmmation or immunologically mediated injury or part of generalized systemic diseases constitute glomerulonephritis.
Classification of Glomerulonephritis Glomerulonephritis.
1. Clinical: Glomerulonephritis
- Acute nephritic syndrome
- Subacute nephritis
- Chronic nephritis
- Chronic renal failure
2. Morphologically based on histological examination:
- Minimal change disease
- Membranous glomerulonephritis
- Focal segmental glomerulonephritis
- Membranoproliferative glomerulonephritis
Glomerulonephritis Etiologic: Glomerulonephritis
- Primary glomerulonephritis
- Secondary due to systemic disease
- Hereditary disorders producing glomerulonephritis.
- Also refer to Ans 1 of same chapter.
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