The student will be able to:

List clinical manifestation of nephritis.

Discuss the pathophysiology of nephrotic
syndrome.
Differentiate between nephritis and nephrotic
syndrome.
Formulate the nursing care plane for patient with
common renal disease such as nephritis and
nephrotic syndrome.
Dysuria: Difficulty or pain on
micturation.

Anuria: Absence of urine.

Oliguria: Decreases in the amount

of urine excreted.

Polyuria: Abnormal increase in the

volume of urine.
Retention: The act of holding back the
urine.

Pyuria: Presence of pus in the urine.

Hematuria: Presence of blood in the

urine.

Albuminuria: Presence of albumin in the

urine.

Azotemia: Increase of the non-protein

nitrogen constituents in blood over 35
mg/100 ml.
Normal Findings:
Structure of the Kidney:
Each kidney contains 1 million nephrons
(nephron = glomerulus +associated tubule).
Number of nephrons is complete at birth, but
functional maturation occurs later.
Normal 24 Hours Urine Collection:

Volume: depends on water intake and losses.

During infancy and early childhood:
• 2 ml /kg /hour, or
• 50 ml/kg /day.
Specific Gravity: 1.015-1.025.
Osmolarity: 300-900 mOsm/Liter.
 Protein: 50-180 mg/24 hours at rest and <
250 mg/ 24 hours after intense exercise.

Glucose: newborn: ≤60 mg/24 h,

thereafter 14 mg/24 hours.

Creatinine: > 15 mg/kg /day.

PSAGN represents the classical
"acute nephritic syndrome"
It is due to non-bacterial
inflammation of glomeruli
secondary to a previous group A-
Beta-hemolytic streptococcal
(GABHS) infection of pharynx or
skin.
Age: 6-7 years.
Sex: both sexes are equally affected.

It occurs as an immune reaction to a group A,

Beta-hemolytic streptococcal infection of the
throat or skin. Nephritis may occur from 1-3
weeks after the onset of infection.
Note: Many cases are asymptomatic and
discovered accidentally when urine is examined
for another reason.
• The body responds to the Streptococcus bacteria
by forming antibodies, which combine with the
bacterial antigens to form immune complexes. As
these antigen-antibody complexes travel through
the circulation, they become trapped in the
glomerulus and activate an inflammatory response
in the glomerular basement membrane.
Glomerulo-nephritis may vary in intensity
from a mild illness to a severe illness
having a sudden onset.
In the usual case:
Evidence of recent streptococcal infection.
Mild edema around the eyes rarely is
generalized (periorbital puffiness).
Temperature is elevated (40° C) but within
a week falls to (37.5° C).
Asymptomatic:
Presenting only with
asymptomatic
microscopic hematuria.
Symptomatic:
• Usually Mild edema around the
eyes rarely generalized, edema
related to decrease glomerular
filtration rate which lead to salt
and water retention.
• Temperature is elevated (40° C)
but within a week falls to (37.5°
C).
• Anorexia, constipation or
diarrhea.
• Hypertension
• Gross hematuria: smoky,
red, tea or cola color.
Presenting with complication:
• Hypertensive encephalopsy
• Renal failure
• Heart failure
A urine analysis reveals hematuria with red cell
casts and Proteinuria is also present but not
severe.
Elevated Blood Urea Nitrogen and creatinine
levels.
Electrolyte disturbances.
Complete blood count reveals mild anemia
Low Serum Complement (C3).

Positive antistreptolysin O titer (ASO).

Culture of the throat or skin lesion.

Chest x-ray shows cardiac enlargement,

pulmonary congestion, or pleural effusion.
In 1-2 weeks: Edema starts to
disappear.
In 2-3 weeks: Gross hematuria,
hypertension and acute renal
failure disappear.
In 1-2 months: Disappearance
of most abnormal urinary
findings.
In 3 months: ESR returns to
normal.
No specific treatment.
Treatment is mainly supportive and
symptomatic.
• Hospitalization and monitoring body
weight, BP, urinary output, and renal
function.
• Diuretics.
• Peritoneal or haemodialysis may be
needed.
• Treatment of streptococcal infection.
• Procaine penicillin 400.000 IU/day, IM, for 10 days, or
• A single IM injection of 1-200.000 IU benzathine
penicillin or
• Oral penicillin V: 200.000-400.000 IU dose, 3
times/day for 10 days or
• Erythromycin: 40 mg/kg/day, orally in 4 divided doses
for 10 days or
• Amoxicillin: 30 mg/kg/day, orally in 3 divided doses for
10 days or
• Cefadroxil: 30 mg/kg/day, orally in 2 divided doses for
10 days.
Differential diagnosis

Other causes of hematuria (infection- exercise-

traumatic- stones hematologic- congenital
abnormalities- tumors- drugs..).

Other cases of edema and proteinuria (e.g.,

minimal changes nephrotic syndrome: see the
following table)
 Nephrotic syndrome is characterized
by heavy proteinuria,
hypoalbuminemia,
hypercholesterolemia, and edema.
 Common in preschool years.
 The average age is 2-3 years (2½
years).
 Boys more than girls are affected
(2:1).
 The cause is unknown.
 Secondary cause such as
chronic nephritis, syphilis,
and nephrotoxic agent.
 The pathogenesis is not under
stood. There may be a metabolic,
biochemical disturbance that causes
basement membrane of the glomeruli
to become increase permeable to
protein. Which leak through the
membrane and are lost in the urine
(hyperalbuminuria) .
 This reduces the serum albumen
level(hypoalbuminemia) ,decreasing
the colloid pressure in the capillaries
.as a result, the vascular hydrostatic
pressure exceed the pull of the colloid
osmotic pressure, causing fluid to
accumulates in interstitial spaces
(edema) and body cavity (ascities) .
 The shift of the fluid to the interstitial
spaces reduce the vascular fluid
volume(hypovolemia) which in turn
stimulates the rennin-angiotensin
system and the secretion of
antidiuretic hormone and
aldosterone.tubular reabsorption of
sodium and water is increased
intravascular volume.
 Edema appears first around the eyes
and at the ankles and later is
generalized. The common sites of
collection are peritoneal cavity
(ascites), the thorax (hydrothorax)
and the scrotum (hydrocele).
 Increased body weight due to edema.
 Diminished urinary output: may occur
with development of edema
 Pain and respiratory difficulty due to
ascitis, pleural effusion and
pulmonary edema.
 Excessive loss of plasma proteins in
the urine with resulting reduction in
serum albumin.
 Pallor and anemia.
 Vomiting, diarrhea and abdominal
distention may occur.
 Anorexia and malnutrition.
 Blood pressure normal or slightly
decreased. But if there is advanced
renal insufficiency hypertension is
seen.
 Irritability and lassitude.
 The child is generally febrile.
Manifestation of complication:

 Infection
 Thrombosis.
 Hypovolemic shock
 Side effect of corticosteroid.
 Diagnostic evaluation
 Proteinuria 3 + to 4+.
 Hypoalbuminemia (<2.5 g/dl)
 Elevated cholesterol and
triglycerides.
1-Increased susceptibility to
infection (Peritonitis Sepsis,
pneumonia, cellulites and urinary
tract infection.), related to:
 Edema fluid in tissues is a good
culture medium.
 Hypoproteinemia
 Decreased immunoglobulin level.
 Decreased splenic function.
 Immunosuppressive therapy.
2-Arterial or venous thrombosis due
to :
 Decreased intravascular volume
 Immobilization
 Diuretic
 Dehydration
3-Hypovolemic shock due to :
 Vomiting, diarrhea.
 Septicemia
 Corticosteroids are the first line of
therapy.
 Diuretics, possible albumin
administration.
 Antibiotics to prevent infection.
No specific treatment. Treatment is mainly
supportive and symptomatic.

Hospitalization and monitoring body weight,

BP, urinary output, and renal function.

Restriction of activity: Not needed except in

acute renal failure or heart failure.
Diet: No restriction except in the acute oliguric
phase (1-2 weeks) for hypertension, heart
failure or renal failure where proteins, sodium,
potassium and fluids are restricte

Diuretics.

Peritoneal or haemodialysis may be needed.

Nursing care plan for child with
acute post-streptococcal
glomerulonephritis