Lecture 11

Acute and Chronic

Glomerulonephritis,
Pediatric Hypertension

By:
GAP Nilawati MD, PAED
I Ketut Suarta MD, PAED
(purna tugas)

URINARY BLOCK
MEDICAL FACULTY OF UDAYANA UNIVERSITY
ACUTE AND CHRONIC GLOMERULONEPHRITIS
 ETIOLOGY OF GLOMERULONEPHRITIS
Alport syndrome, congenital nephrotic syndrome (Finlandia Type)
Familial hematuria, nail patella syndrome
Acquired
Primary/ idiopathic
Minimal change disease, mesangial proliferative glomerulonephritis
Focal segmental glomerulosclerosis
Membranoproliferative glomerulonephritis
Membranous glomerulonephropathy
IgA nephropathy
Rapid progressive glomerulonephritis, diffuse proliferative glomerulonephritis
Other chronic glomerulonephritis (unclassified)
Secondary
Infection
Acute poststreptococcal glomerulonephritis, Hepatitis B, subacute bacterial endocarditis
Postpneumococcal glomerulonephritis, congenital syphilis, malaria
Lepra, schistosomiasis, filariasis, HIV AIDS
Secondary due to multisystem disease
HSP, SLE, Hemolytic uremic syndrome
Diabetes mellitus, goodpasture syndrome, amyloidosis
Vascular collagen disease, wagener granulomatosis, rheumatoid arthritis
Secondary due to drug
Penisilamin, NSAID, captopril
Street heroin, trimetadion, lithium, mercury
Secondary due to neoplastic
Leukemia, lymphoma, carcinoma
Others
Chronic rejection renal transplant, reflux nephropathy, sickle cell anemia
 Acute Glomerulonephritis (AGN)
▪ The proliferation & inflammation on Glomerulus as a result of immunologic
mechanism
▪ Clinical → nephritic syndrome
▪ Proteinuria
▪ Hematuria
▪ Hypertension
▪ Edema
▪ Oligouria
▪ Fluid Overload
▪ Insufficiency kidneys, C3 ↓
Etiology
▪ Post-infection
▪ Streptococcus  Hemolitikus group A (GNAPS)→Most often →
Location → pharynx infections and skin
▪ Other bacteria, viruses, parasites etc.

Epidemiology
• Age: - school age (6-7 yo)
- rarely < 3 yo
• Male : female = 2:1
Pathophysiology
▪ The immune system (complex Ag-Ab) → Streptococcal antibodies (ASTO) increased
▪ Complement C3 Active →level of C3 declined

Clinical manifestation→ nephritic syndrome

▪ Asimptomatic >>
▪ The latent period → streptococcal infections
▪ Throat 1-2 weeks
▪ The skin 3 weeks
▪ Common symptoms/Non spesifik
→ anorexia, malaise, fever, headache, etc.
▪ Gross hematuria 65 %
▪ Edema 75 %
▪ Hypertension 50 %
▪ Oliguria 5-10 %
Clinical Course of Acute Glomerulonephritis
The Laboratory Evaluation :
▪ Complete urination (UL)
▪ Proteinuria
▪ Hematuria
▪ Erythrocytes Cast
▪ ASTO ↑
▪ C3 ↓
▪ BUN/SC ↑ GFR → ↓
 THERAPY COMPLICATION
▪ Supporting Therapy ▪ Edema of the lungs
▪ Diet : salt 1 gram/day ▪ Renal failure
▪ According to the fluid
▪ Heart failure
requirements
▪ Encephalopathy hyperten
▪ Symptomatic therapy
sion
▪ Antibiotics
▪ Antihypertensives
The natural history of the disease :
• Good → 95 % recovery
• 5 % GNC
• Diuretic, edema, hypertension → disappeared 7-10 day
• Proteinuria being normal in 3-6 month
• BUN/SC improved in 1 week → being normal in 3-4 week
• C3 normal in 6-8 week
• Gross hematuria:
- Improved within days
- microscopic hematuria sometimes settled in few moths-years
• Mortality is 0-7% caused by:
- Septicemia
- Heart failure
- Encephalopathy
 CHRONIC GLOMERULONEPHRITIS (CGN)

▪ Glomerular disorders that do not improve quickly as AGN

▪ Permanent loss of nephron mass

Clinically diagnosis :
- Asymptomatic Persistent proteinuria / hematuria
- Nephrotic syndrome
- Nephritic syndrome

Often progressive to chronic kidney disease

 ETIOLOGY OF CGN
▪ Membranoproliferative Glomerulonephritis : 90%
cases lead to CKD
▪ Iga Nephropathy : 20-40% cases lead to CKD
▪ HSP : 1-2% cases
 MANAGEMENT

▪ Progression to ESRD in adolescents with chronic GN may be

delayed or even avoided with attention to the principles of
renoprotection (aggressive control of hypertension and
proteinuria)
▪ Primary care physician : monitoring control of hypertension,
encouraging compliance with medications, and stressing the
importance of regular follow-up by the nephrologist.
PEDIATRIC HYPERTENSION
 PEDIATRIC HYPERTENSION
The blood pressure in children depend on:
▪ Age
▪ Gender
▪ Height (Use the CDC curve)

The value of blood pressure on children also influenced by the size

of the the cuff

Hypertension (HTN) on children can be caused by :

• Primary / Essential
• Secondary >>
 ETIOLOGY OF PEDIATRIC HYPERTENSION

Age Common Cause

Newborn Renal artery thrombosis or embolus, Renal vein thrombosis, Congenital renal
malformations, Coarctation of aorta, Renal artery stenosis, Bronchopulmonary
dysplasia
Infancy to 6 Renal parenchymal disease, Renal artery stenosis, Coarctation of the aorta,
years Medications (corticosteroids, albuterol, pseudoephedrine), Endocrine causes

6-10 years Renal parenchymal disease, Renal artery stenosis, Primary hypertension, Endocrine
causes.
Adolescence Primary hypertension, White coat hypertension, Renal parenchymal disease,
Substance abuse (cocaine, amphetamines, methamphetamines, phencyclidine,
methylphenidate, caffeine), Teen pregnancy, Endocrine causes.
MECHANISM OF
HYPERTENSION
 THE SIZE OF THE THE CUFF TENSIMETER
▪ Neonates : the width of the cuff (2.5- 4 cm) the length of the cuff (5-9 cm)
▪ Baby : W (4-6 cm) L (11.5 - 18 cm)
▪ Children : W (7.5- 9 cm) L (17-19 cm)
▪ Adults : W (11.5 - 13 cm) L (22-26 cm)
▪ Bigger arm : W(14-15 cm) L (over 30.5- 33 cm)
▪ Thigh : W (18-19 cm)L (36-38 cm)
Description :
W: the width of the pouch
L : The length of the pouch
 Definitions of BP Categories and Stages
(The American Academy of Pediatrics (AAP) and its Council on Quality Improvement and Patient Safety, 2017)

For Children Aged

Categories
1-13 y 13 y
Normal BP 90th percentile <120/<80 mmHg
Elevated BP 90th percentile to 95th percentile or 120/<80 to 129/<80mmHg
120/80 mmHg to 95th percentile
(whichever is lower)
Stage 1 HTN 95th percentile to 95th percentile + 130/80 to 139/89 mmHg
12 mmHg, or 130/80 to 139/89 mmHg
(whichever is lower)
Stage 2 HTN 95th percentile + 12 mmHg, or 140/90 mmHg
140/90 mmHg (whichever is lower)
THE PERCENTILE CURVE OF HEIGHT
 DRUG OF CHOICE
Class of drugs Type Dose Maximal Dose

A n g i o t e n s i n Captopril 0.3 – 0.5 mg/kg/dose (q8 hours) 6 mg/kgBW/daily (50 mg q 8

Converting hours)
Enzyme inhibitor
(ACEi) Enalapril 0.08 mg/kg/dose 1 mg/kg/daily (40 mg daily)

Lisinopril 0.07 mg/kg/dose 1 mg/kg/dose (10-20 mg daily)

Angiotensin II Losartan 0.5 mg/kg/dose (q 24 hours) 1.4 mg/kg/dose (100 mg daily)

Receptor Blockers
(ARB)

Valsartan < 6 yo : 5-10 mg q 24 hrs 1.4 mg/kg/dose (80 mg daily)

≥ 6yo : 1.3 mg/kg q 24 hrs 160 mg daily

Beta blocker Propanolol 0.2-0.5 mg/kg/dose (q6-12 hrs) 2 mg/kg/dose (80 mg/dose)
Class of drugs Type Dose Maximal Dose

Calcium Nifedipine 0.25 mg/kg/dose (q 6-8 hours) 0.5 mg/kg/dose (20 mg daily)
channel
blocker
Amlodipine 0.05 mg/kg daily (q24 hours) 0.2 mg/kg daily

Diltiazem 2 mg/kg 3.5 mg/kg

Diuretic Furosemide 1 mg/kg/dose (q 6-12 hours) 12 mg/kg daily (240 mg q 4-6

hours)

Spironolactone 1 mg/kg/dose (q 12-24 hours) 3 mg/kg daily (100 mg daily)

 STEP DOWN THERAPY
Infant Controlled blood pressure rise for 1 month
The drug dose did not increase, and the baby continued to grow
Blood pressure remains constant and under control The dose of
the drug was reduced to once a week and gradually discontinued
Children or Blood pressure controlled within normal limits for 6 months to 1 year
adolescent Control blood pressure at intervals of 6-8 weeks
Change to monotherapy
Once control lasts approximately 6 weeks, decrease monotherapy each
time weeks and if possible gradually discontinued
Explain the importance of non-pharmacological treatment for control
blood pressure
Explain the importance of continuously monitoring blood pressure, and
that pharmacologic therapy may be required at any time