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Case Report

Acute
Glomerularnephri
tis
Preceptor:
dr. Ulinar M., Sp.A
Compiled by:
Michael S. Rampangilei
07120080106
FACULTY OF MEDICINE UNIVERSITY OF PELITA HARAPAN
DEPARTMENT OF PEDIATRICS CLINICAL CLERKSHIP
BHAYANGKARA TK. 1 R. SAID SUKANTO HOSPITAL
DECEMBER 23RD-MARCH 1ST 2014 PERIOD

IDENTITY
Name
:N
Gender
: Male
Age
: 10 Years 6 Months
Address
: Cigudeg
Weight
: 29kg
Height
: 130cm
Date of admission : 22nd December 2013
Date of examination
: 22nd December 2013

ANAMNESIS

Chief and additional


complaints
Auto- and alloanamnesis to the patient and his
mother
Chief Complaint
Hip pain since 9 days before hospital admission
Additional Complaint
Abdominal pain, nausea, vomiting, fever,
constipation, both eyes swollen

History of the present


illness
The patient complained of a dull pelvic pain that started 9 days before being
admitted to the hospital. The pain radiates towards the front central torso. 6
days before hospital admission, the patient woke up with both eyelids
swollen and complained of a blurry vision. Patient was taken to RS MISI
diagnosed with Acute Glomerulonephritis and undefined eye illness. The
patient consulted with an ophthalmologist but no pathologies were
discovered. During urination, the color was dark tea like, no pain is
evident. The patient has also experienced nausea and frequent vomiting 45x/day since the initial symptom. A day before the pelvic pain, the patient
endured a constant fever recorded by the mother at 38,8C, that was
relieved by consuming paracetamol temporarily. The last time the patient
defecated was 3 days before being admitted. The patient suffered a cough
and runny nose 2 days before hospital admission.
The patient said that he didnt consume any drugs before the onset of his
sickness and he doesnt have any allergy to some food or medicine. There
werent any patients family, relatives, or friends who had the same
symptoms.

Past diseases history


Pharyngitis/tonsillitis: (+)
Bronchitis
Pneumonia

: (-)
: (-)

Morbili

: (+)

Pertussis

: (-)

Varicela

: (-)

Diphteriae

: (-)

Malaria

: (-)

Polio

: (-)

Enteritis

: (-)

Family History
Parents married: once for a mother, once for a
father
Patients father is healthy
Patients mother is healthy
People surrounding the patient is healthy
History of siblings
Year

Gestation
al age

Method of
delivery

Sex

Birthweig
ht

2003

9 months

Normal

Male

3000 gram

Past obstetric state


Prenatal care
Antenatal care is done regularly at the local clinic
Sickness while pregnant: -

Pregnancy history
Gestational age: 40 weeks (normal)
Born at Home
Delivered by a midwife
Born by normal delivery, cried directly after
delivery
Weight: 3000 gram (normal: 2500-4000 gram)
Height: 49cm (normal: 45-54 cm)

Growth and developmental


state

Vaccination
BCG

: 1x

Varicella

: 0x

DPT

: 3x

Polio

: 4x

Hepatitis B
Measles

: 3x

: 2x

Other vaccinations

:-

Patients been given fundamental


vaccination according to the
governments law.

Food intake
Breastfeeding since born until 9 months old
Started be given formula milk since the age of
10 months. The milk was dancow.
Fruits have been given since the age of 10
months (banana and papaya)
Vegetables been given since the age of 10
months (carrot and celery)
Condensed food been given since the age of
1,5 year old (rice, egg, beef meat, chicken
meat, and fish).
Quantity and quality of the food intake, in
overall is considered as sufficient

PHYSICAL
EXAMINATIO
N
Done on December 22rd 2013 (1st day of medical care)

Vital signs
General condition

: Patients looks moderately ill

Level of consciousness
Blood Pressure
Pulse Rate

:Compos Mentis, GCS 15 (E4M6V5)

: 150/80 mmHg
: 90x/minute, regular, adequate

Respiratory Rate
Axillary temperature

: 22x/minute
: 36,7C

Nutritional status
Weight

: 29 kg

Height

: 130 cm

Weight for Age

: 29/30= 96,67%

Height for Age


94,90%

: 130/137 =

Weight for Height : 29/ 27=


107,41%
Interpretation : Normoweight

General examination
Head :
Normocephaly
Deformity (-)

Eyes :
Pale conjunctiva -/ Icteric sclera -/ Secretions -/ Pupil is rounded, isochore 3mm/3mm
Direct light reflex +/+
Indirect light reflex +/+
Edema Palpebra +/+

Nasal:
Septum is in the middle, deviation (-)
Secretions -/ Nasal flaring -/-

Ear:
External acoustic meatus +/+
Timpanyc membrane is intact +/+
Cerumen -/ Secretions -/-

Mouth

Wet lips
Oral mucous is wet, kopliks spot (-)
Tongue is wet, coated tongue (-)
Pharyx is hyperemic (+)
Tonsil is T2/T3

Neck :
Intact trachea in the middle
Mass (-)
Enlarged lymph nodes (-)

Thorax
Pulmo
Inspection: symmetrical breathing movements
Palpation: Stem fremitus on the right and the left were
equivalent
Percussion: Sonor in both lungs field
Ausculation: Vesicular breath sound +/+, wheezing -/-,
rhonchi -/ Cardio
Inspection: Ictus cordis was unseen
Palpation : Ictus cordis was palpated on the 5th intercostal
left midclavicular line
Percussion : Cardiomegaly (-)
Auscultation : S1 and S2 regullar, gallop (-), murmur (-)

Abdomen
Inspection: Flat abdomen
Auscultation: Bowel sound (+) 2-3x/minute
Palpation: Tenderness (-), hepatomegaly (-),
splenomegaly (-), muscular defense (-)
Percussion: Timpany on all abdominal region

Extremities :
Warm
Capillary refill time < 3 seconds
Edema (-)

LABORATORY
S
EXAMINATION

December 18th 2013


Examination

Result

Unit

Normal Value

Hemoglobin

10,7

g/dl

Boy : 13-18; Girl : 12-16

Hematocrit

31

Boy : 40-58; Girl : 37-43

Leukocyte

9,200

/L

5.000-10.000

Thrombocyte

242.000

150.000-500.000

SGOT

23

/L

SGPT

10

/L

Basophil

0-1

Eosinophil

1-3

Batang

2-6

Segmen

63

50-70

Limfosit

25

20-40

Monosit

12

0-1

Hematology I

HitungJ enis

Examination

Result

Unit

Normal Value

Urinalysis
Color

Yellow

Clearity

Cloudy

pH

5.5

5.5-8.5

Weight

1.025

1.000-1.030

Protein

+3

Negative

Bilirubin

+1

Negative

Glucose

Negative

Keton

Negative

Blood/ Hb

+1

Negative

Nitric

Negative

Urobilinogen

0,1

Leukocyte

IU

0,1-1,0
Negative

Sediment
Leukocyte
Erithrocyte
Epithelial cells
Cyclinder
Crystal
Others

6-7

/ 40x FOV

Negative

7-14

/ 40x FOV

Negative

5-8

/ 40x FOV

Negative

/ 40x FOV

Negative

+amorf

/ 40x FOV

Negative

Negative

December 22nd 2013


Examination

Result

Unit

Normal Value

Hemoglobin

11,5

g/dl

Boy : 13-18; Girl : 12-16

Hematocrit

33

Boy : 40-58; Girl : 37-43

Leukocyte

7.600

/L

5.000-10.000

Thrombocyte

361.000

/L

150.000-500.000

Erythrocyte

4.38

Million/ul 4.5-5.5

Hematology I

Examination

Result

Unit

Normal Value

Ureum

125

mg/dl

10 - 50

Creatinine

2,2

mg/dl

0,5 1,5

Random Blood Glucose 114

mg/dl

<200

Clinic Chemistry

December 23rd 2013


Examination

Result

Unit

Normal Value

CompleteFeces Exam
Color

Brown

Consistency

Soft

Mucus

Blood

Leukocyte

+1-2

Negative

Erythrocyte

0-1

Negative

Microscopic

Examination

Result

Unit

Normal Value

Hemoglobin

10,7

g/dl

Boy : 13-18; Girl : 12-16

Hematocrit

30

Boy : 40-58; Girl : 37-43

Leukocyte

7,700

/L

5.000-10.000

Thrombocyte

342.000

150.000-500.000

LED

60

<15

Basophil

0-1

Eosinophil

1-3

Batang

2-6

Segmen

61

50-70

Limfosit

31

20-40

Monosit

0-1

Hematology III

HitungJ enis

Examination

Result

Unit

Normal Value

Total Protein

30

g/dl

6.0 8.7

Albumin

2,2

g/dl

3.5 5.2

Globulin

2,6

g/dl

2.5 3.1

Bilirubin Total

0,20

Mg/dL

<1.5

Bilirubin Direct

0,07

Mg/dL

<0.5

Indirect Bilirubin

0,13

Mg/dL

<1.0

SGOT

71,4

<37

SGPT

50,1

<40

Total Cholesterol

156

Mg/dL

<200

HDL

18

Mg/dL

35 - 55

LDL

90

Mg/dL

<160

Tryglyceride

242

Md/dL

<200

Ureum

172

Mg/dL

10 50

Creatinine

1,8

Mg/dL

0,5 1,8

Sodium

132

Mmol/L

135 145

Potassium

4,4

Mmol/L

3,8 5,0

Chloride

106

Mmol/L

98 - 106

Liver Funtion Test

Lemak Lengkap

Electrolytes

Examination

Result

Unit

Normal Value

Urinalysis
Color

Yellow

Clearity

Cloudy

pH

5.5

5.5-8.5

Weight

1.020

1.000-1.030

Protein

+3

Negative

Bilirubin

Negative

Glucose

Negative

Keton

Negative

Blood/ Hb

+2

Negative

Nitric

Negative

Urobilinogen

0,1

Leukocyte

IU

0,1-1,0
Negative

Sediment
Leukocyte

4-5

/ 40x

Negative

FOV
Erithrocyte

21-23

/ 40x

Negative

FOV
Epithelial cells

/ 40x

Negative

FOV
Cyclinder

Granular 1 -2

/ 40x

Negative

FOV
Crystal

/ 40x

Negative

FOV
Others

Negative

December 26th 2013


Examination

Result

Unit

Normal Value

Hemoglobin

10,4

g/dl

Boy : 13-18; Girl : 12-16

Hematocrit

31

Boy : 40-58; Girl : 37-43

Leukocyte

13.600

/L

5.000-10.000

Thrombocyte

284.000

/L

150.000-500.000

Ureum

47

Mg/dL 10 - 50

Creatinine

0,9

Mg/dL 0,5 1,5

Hematology I

26th of December 2013

RESUME

A 10 years 6 months old boy patient, came to the


emergency department of Polri Hospital on December
20th 2013 with the chief complaint of a dull pelvic
pain that started 9 days before being admitted to the
hospital. The pain radiates towards the front central
torso. Both of the patients eyelids swollen and
caused a blurry vision. The patients urine color was
dark tea like. The patient has also experienced
nausea and frequent vomiting 4- 5x/day since the
initial symptom. A fever recorded by the mother at
38,8C, that was relieved by consuming paracetamol
temporarily. Patient also presented with constipation.
The patient suffered a cough and runny nose 2 days
before hospital admission.

Physical examination on December 23 rd 2013:


General condition: Patients looked moderately ill
Level of consciousness
(E4M6V5)
Blood Pressure

:Compos Mentis, GCS 15

: 150/80 mmHg

Pulse Rate : 90x/minute, regular, adequate


Respiratory Rate : 22x/minute
Axillary temperature : 36,7C
Further examination:
Laboratory shows hyperurecemia, increased LFT,
micro hematuria, proteinuria, Hypertryglyceride

DIAGNOSIS
A 10 years 6 months old boy patient,
with weight 29 kg, and height 130
cm, been sick for 8 days, and
receiving his 4th day of medical care,
with working diagnosis of:
Acute Glomerulonephritis with
Secondary Hypertension
Acute Tonsillopharyngitis
Growth and development is
appropriate with age
Fundamental vaccination have been
completely given

TREATMENT
IVFD Ringer Lactate maintenance
2000 cc/24jam
Cefotaxime IV 2x750mg
Lasix tablet 1x30mg
Captopril 2 x 5mg

PROGNOSIS
Quo ad vitam

: Dubia ad Bonam

Quo ad functionam

: Dubia ad Bonam

Quo ad sanationam

: Dubia

FOLLOW-UP
2ND day of medical care

Fever (-), eyelids are still swollen and still the complain of nausea

General condition

: Patient looked moderately ill

Level of consciousness: Compos Mentis, GCS 15 (E 4M6V5)


Blood Pressure

: 140/90 mmHg (Normal: 100-120/60-75)

Pulse Rate

: 90x/minute, regular, adequate (Normal :60-100x/minute)

Respiratory Rate

: 22x/minute (Normal: 16-20x/minute)

Axillary temperature : 36,8C


A
P

10th day of acute glomerulonephritis

IVFD Ringer Lactate maintenance 2000 cc/24jam

Cefotaxime IV 2x750mg

Lasix tablet 1x30mg

Captopril 2 x 5mg

3RD day of medical care

Fever (-), eyelids are still swollen, fullness of the abdomen

General condition

: Patient looked moderately ill

Level of consciousness: Compos Mentis, GCS 15 (E 4M6V5)


Blood Pressure

: 130/80 mmHg (Normal: 100-120/60-75)

Pulse Rate

: 70x/minute, regular, adequate (Normal :60-100x/minute)

Respiratory Rate

: 20x/minute

(Normal: 16-20x/minute)

Axillary temperature : 36C


Extremities
A
P

: Swollen lower extremities

11th day of acute glomerulonephritis

Released from the hospital IVFD Ringer Lactate maintenance 2000 cc/24jam

Cefotaxime IV 2x750mg

Lasix tablet 1x30mg

Captopril 2 x 5mg

4th day of medical care

Fever (-), eyelids are still swollen, fullness of the abdomen, shortness of breath

General condition

: Patient looked moderately ill

Level of consciousness: Compos Mentis, GCS 15 (E4M6V5)


Blood Pressure

: 110/70 mmHg (Normal: 100-120/60-75)

Pulse Rate

: 88x/minute, regular, adequate (Normal :60-100x/minute)

Respiratory Rate

: 28x/minute (Normal: 16-20x/minute)

Axillary temperature : 36,5C


Abdomen
A
P

: Shifting Dullness (+)

12th day of acute glomerulonephritis

IVFD Ringer Lactate maintenance 2000 cc/24jam

Cefotaxime IV 2x750mg

Lasix tablet 1x30mg

Captopril 2 x 5mg

5th day of medical care

Fever (-), eyelids are still swollen,

General condition

: Patient looked moderately ill

Level of consciousness: Compos Mentis, GCS 15 (E4M6V5)


Blood Pressure

: 100/60 mmHg (Normal: 100-120/60-75)

Pulse Rate

: 80x/minute, regular, adequate (Normal :60-100x/minute)

Respiratory Rate

: 24x/minute (Normal: 16-20x/minute)

Axillary temperature : 36C


A
P

13th day of acute glomerulonephritis

IVFD Ringer Lactate maintenance 2000 cc/24jam

Cefotaxime IV 2x750mg

Lasix tablet 1x30mg

Captopril 2 x 5mg

6th day of medical care

Headache and Fatigued

General condition

: Patient looked moderately ill

Level of consciousness: Compos Mentis, GCS 15 (E 4M6V5)


Blood Pressure

: 160/90 mmHg (Normal: 100-120/60-75)

Pulse Rate

: 84x/minute, regular, adequate (Normal :60-100x/minute)

Respiratory Rate

: 20x/minute (Normal: 16-20x/minute)

Axillary temperature : 37C


A
P

14th day of acute glomerulonephritis

IVFD Ringer Lactate maintenance 2000 cc/24jam

Cefotaxime IV 2x750mg

Lasix tablet 1x30mg

Captopril 2 x 5mg

Albumin 20% 50cc

7th day of medical care

Headache

General condition

: Patient looked mildly ill

Level of consciousness: Compos Mentis, GCS 15 (E4M6V5)


Blood Pressure

: 130/80 mmHg (Normal: 100-120/60-75)

Pulse Rate

: 80x/minute, regular, adequate (Normal :60-100x/minute)

Respiratory Rate

: 20x/minute (Normal: 16-20x/minute)

Axillary temperature : 36,6C


A
P

15th day of acute glomerulonephritis

IVFD Ringer Lactate maintenance 2000 cc/24jam

Cefotaxime IV 2x750mg

Lasix tablet 1x30mg

Captopril 2 x 5mg

8th day of medical care

General condition

: Patient looked mildly ill

Level of consciousness: Compos Mentis, GCS 15 (E4M6V5)


Blood Pressure

: 120/90 mmHg (Normal: 100-120/60-75)

Pulse Rate

: 76x/minute, regular, adequate (Normal :60-100x/minute)

Respiratory Rate

: 20x/minute (Normal: 16-20x/minute)

Axillary temperature : 36C


A
P

16th day of acute glomerulonephritis

IVFD Ringer Lactate maintenance 2000 cc/24jam

Cefotaxime IV 2x750mg

Lasix tablet 1x30mg

Captopril 2 x 5mg

9th day of medical care

General condition

: Patient showed substantial improvement than the day before

Level of consciousness: Compos Mentis, GCS 15 (E 4M6V5)


Blood Pressure

: 110/80 mmHg (Normal: 100-120/60-75)

Pulse Rate

: 88x/minute, regular, adequate (Normal :60-100x/minute)

Respiratory Rate

: 20x/minute (Normal: 16-20x/minute)

Axillary temperature : 36,3C


A

Released from the hospital

Acute Glomerulonephritis

Background

Definition:
The failure of kidneys to process and regulate its physiological function due to the
immunologic mechanism that triggers inflammation and proliferation of glomerular tissue
which in turn result in the damage to the basement membrane, mesangium, or capillary
endothelium.

Hippocrates originally described the manifestation of back pain and hematuria,


which lead to oliguria or anuria. With the development of the microscope,
Langhans was later able to describe these pathophysiologic glomerular changes.
Acute GN is defined as the:
Sudden onset of hematuria
Proteinuria, and
Red Blood Cell (RBC) casts

Fundamental Kidney
Anatomy and Function

8 fundamental function of the Kidneys:


Excretion of Metabolic Waste and Foreign
Substances
Regulation of Water and Electrolyte Balance
Regulation of Extracellular Fluid Volume
Regulation of Plasma Osmolality
Regulation of Red Blood Cell Production
Regulation of Vascular Resistance
Regulation of Acid-base Balance
Regulation of Vitamin D Production
Gluconeogenesis

Etiology

Infectious
Streptococcus species (ie, group A, beta-hemolytic)
Serotype 12 - upper respiratory infection
Serotype 49 - skin infection

Staphylococci
Mycobacteria
Brucella suis
Treponema pallidum
Corynebacterium bovis
CMV
EBV

Non-Infectious
Primary Renal Disease

Membranoproliferative Glomerulonephritis
Berger Disease
Pure Mesangial Proliferation
Systemic Disease
HSP
Vasculitis (Wegener Granulomatosis)
SLE
Polyarteritis nodosa
Goodpasture Syndrome
Miscellaneous Disease

Guillain-Barr syndrome
Irradiation of Wilms tumor
Diphtheria-pertussis-tetanus (DPT) vaccine

Pathophysiology
fPSGN

Inflamation of
Glomerular
tufts
Endothelial,
Epithelial,
Mesangial Cellular
Proliferation
Hyalinization/Sc
lerosis

Formation
of Immune
Complexes

Glomeruli
Deposition

Extracapillary

Endocapillary
Glomerular
Basement
Thickening

NPSGN

50% Kidney
Enlargement

Increased number
of cells in
Glomerular tufts

Glomeruli
Deposition

DIAGNOSIS

Disease Presentation
HISTORY
Identification of an underlying systemic disease (if any) or
recent infection. Use of intravenous medications
Triad of sinusitis, pulmonary infiltrates, and nephritis Wegener
granulomatosis
Nausea and vomiting, abdominal pain, and purpura, HenochSchnlein purpura
Arthralgias, associated with systemic lupus erythematosus (SLE)
Hemoptysis, occurring with Goodpasture syndrome or idiopathic
progressive glomerulonephritis
Skin rashes, observed with hypersensitivity vasculitis or SLE

Risk Factor: Male, aged 2-14 years, who suddenly develops puffiness of
the eyelids and facial edema in the setting of a poststreptococcal
infection.
Urine:
Dark and scanty

Blood pressure may be elevated.


Nonspecific symptoms:
Weakness,
Fever
Abdominal pain
Malaise

Onset and duration of the illness:


Symptom onset is usually abrupt.
The onset of nephritis within 1-4 days of streptococcal infection

Assess the consequences of the disease process (uremic symptoms):


Inquire about loss of appetite,
Generalized itching and tiredness,
Nausea
Easy bruising
Nosebleeds
Facial swelling
Leg edema

Inquire about symptoms of acute glomerulonephritis, including the


following:

Hematuria (smoky-, coffee-, or cola-colored urine)


Oliguria
Edema (peripheral or periorbital) - This is reported in
approximately 85% of pediatric patients; edema may be mild
(involving only the face) to severe,
Headache - This may occur secondary to hypertension;
confusion secondary to malignant hypertension may be seen
in as many as 5% of patients.
Shortness of breath or dyspnea on exertion - This may occur
secondary to heart failure or pulmonary edema; it is usually
uncommon, particularly in children.
Possible flank pain secondary to stretching of the renal capsule

PHYSICAL EXAMINATION
Patients present with a combination of edema, hypertension,
and oliguria.
The physician should look for the following signs of fluid
overload:
Periorbital and/or pedal edema
Edema and hypertension due to fluid overload (in 75% of
patients)
Crackles (ie, if pulmonary edema)
Elevated jugular venous pressure
Ascites and pleural effusion (possible)

The physician should also look for the following:


Rash (as with vasculitis, Henoch-Schnlein purpura, or lupus nephritis)
Pallor
Renal angle (ie, costovertebral) fullness or tenderness, joint swelling, or
tenderness
Hematuria, either macroscopic (gross) or microscopic
Abnormal neurologic examination or altered level of consciousness (from
malignant hypertension or hypertensive encephalopathy)
Arthritis

Other signs include the following:


Pharyngitis
Impetigo
Respiratory infection
Pulmonary hemorrhage
Heart murmur (possibly indicative of endocarditis)
Scarlet fever
Weight gain
Abdominal pain
Anorexia
Back pain
Oral ulcers

Progression of Disease
Progression to sclerosis is rare in the typical patient
0.5-2% of patients with acute GN, the course progresses toward renal failure, resulting in
kidney death in a short period.

Abnormal urinalysis (ie, microhematuria) may persist for years.


Marked decline in the glomerular filtration rate (GFR) is rare.
Pulmonary edema and hypertension may develop.
Generalized anasarca and hypoalbuminemia may develop secondary to severe
proteinuria.
End-organ damage in the central nervous system (CNS) or the cardiopulmonary
system can develop in patients who present with severe hypertension,
encephalopathy, and pulmonary edema. Those complications include the
following:
Hypertensive retinopathy
Hypertensive encephalopathy
Rapidly progressive GN
Chronic renal failure
Nephrotic syndrome

Workup
Complete Blood Count
Urinalysis and Sediment
Blood Urea Nitrogen
Serum Ureum and Creatinine
Electrolytes
Erythrocyte Sedimentation Rate
Ultrasonography
Streptozyme Tests
Blood and Tissue Culture
NAPR
Renal Biopsy

Differential Diagnosis
The following 4 renal syndromes commonly
mimic the early stage of acute
glomerulonephritis (GN):
Anaphylactoid purpura with nephritis
Chronic GN with an acute exacerbation
Idiopathic hematuria
Familial nephritis

Immunoglobulin A (IgA) nephritis


The latent period between infection and onset of nephritis is 1-2
days
Nephritis may be concomitant with upper respiratory tract
infection

Lupus nephritis
Gross hematuria is unusual in lupus nephritis.

GN of chronic infection
Manifest as acute nephritis
Unlike PSGN, in which the infection may have resolved by the time
nephritis occurs, patients with nephritis of chronic infection have
an active infection at the time nephritis becomes evident.
Circulating immune complexes play an important role in the

Management

Key Concept SUPPORTIVE THERAPY.


Pharmacological Agents
Antibiotics
Diuretics
Antihypertensives/Vasodilator Drugs
Glucocorticoids
Diet and Activity
Sodium and fluid restriction
Protein restriction for patients with * no evidence of no malnutrition
Bed rest is recommended until signs of glomerular inflammation
and circulatory congestion subside.

Antibiotics
Penicillin V(500 mg PO q12hr or 250 mg PO q6hr for 10 days)
250 mg of penicillin V = 400,000 U of penicillin.

Cephalexin (25-50 mg/kg/day PO divided q6-8hr for 10 days; 4 g/day


maximum)
The recommended dosing schedule of erythromycin may result in GI upset,
causing one to prescribe an alternative macrolide or to change to thrice-daily
dosing. Erythromycin covers most potential etiologic agents, including
mycoplasmal species.

Erythromycin (Mild-to-moderate infections: 30-50 mg/kg/day PO divided


q6-12hr, Severe infection: 60-100 mg/kg/day PO divided q6-12hr)
In children, age, weight, and severity of infection determine the proper dosage.
When twice-daily dosing is desired, half the total daily dose may be taken
every 12 hours. For more severe infections, double the dose.
Erythromycin has the added advantage of being a good anti-inflammatory
agent by inhibiting the migration of polymorphonuclear leukocytes.

Loop Diuretics

Loop diuretics decrease plasma volume and edema by causing diuresis.


The reductions in plasma volume and stroke volume associated with
diuresis decrease cardiac output and, consequently, blood pressure.
Furosemide (Lasix)
Initial Dosage: 1 2mg/kg/hr (PO/IV)
Increased Dosage: 1 2mg/kg/6 8hr (PO) OR 1mg/kg/ 2hr (IV)
Maximum Dose: 6mg/kg/day
Increases excretion of water by interfering with the chloride-binding
cotransport system, inhibiting sodium and chloride reabsorption in the
ascending loop of Henle and the distal renal tubule.
Rapidly absorbed from the gastrointestinal (GI) tract.
The diuretic effect is apparent within 1 hour of oral (PO) administration and
lasts for 4-6 hours.
After intravenous (IV) administration, diuresis occurs within 30 minutes; the
duration of action is about 2 hours

Antihypertensives
Amlodipine (6 years: 2.5-5 mg/day PO)
Labetalol (0.4-1 mg/kg/hr by continuous IV
infusion; not to exceed 3 mg/kg/hr)
Nifedipine (0.25-0.5 mg/kg/day (extended
release) PO in 1 or 2 daily doses initially; not to
exceed 3 mg/kg/day (120 mg/day)
Hydralazine (Maximum dose in children: 7.5
mg/kg/day divided q12hr PO)
Nitroprusside 10 mcg/kg/min (6 mcg/kg/min in
neonates)

Prognosis
Long-term studies on children with PSGN have
revealed few chronic sequelae
Long-term studies show higher mortality rates
in elderly patients
Patients may be predisposed to crescent
formation

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