Glomerulonefritis Akut

Poststreptokokus
David Yobel / E4 / 102013408
SKENARIO
 Anak laki-laki 5 tahun
 Buang air kecil gelap, oliguria
 Bengkak di kedua mata
 Nafas pendek 2 hari yang lalu
 1-2 minggu setelah pharyngitis
 3-4 minggu setelah impetigo
 Grup A beta-hemoliticus
 Nephritogenic M (1, 2, 4, 12, 18, 25, 49, 55, 57, 60), unclassified, 49, 55, 57, 60 – skin
 GNA - Complete heal
 Rheumatic – relapsing
 Imumnologic process – cellular and humoral
 Glomerular trapping of circulating immune complexes
 In situ Ag-Ab complex – molecular mimicry
 Protein with unique antigenic – bind to glomerulus – active complement (properdin) – immune
complex
 Nephritis strain-associated protein (NSAP) , zymogen precursor exotoxin B – plasminogen activator
(sama seperti streptokinase pada grup C)
 Nephritis-associated plasmin receptor (NAPIr), glycolytic enzyme – preabsorbing antigen (PA-Ag)
 SPEP (nephrogenic antigen) – secreted as exotoxin
 NAPlr binds to glomeruli - capture plasmin activated by NSAP
 Activated plasmin bound to NAPlr associates GBM and mesangium – chemotactic, IL6
 Bound plasmin - tissue destruction
 NAPlr - complement pathway, PMN and macrofag - accumulate on the subepithelial space as humps
Lab
 Streptozyme test
 C3 menurun > 6-8 minggu – MPGN
 Anemia
 Creatinin dan BUN meningkat
 Proteinuria < 3+, Hematuria (gross dan mikroskopik)
 Hyaline dan cellular silinder
 Biopsi: diffuse hypercellularity, infiltration glomerular tuft with PMN, deposit IgG dan C3
 Tidak ditemukan riwayat infeksi streptococcus
 Normocomplementemia
 GFR < 30 ml/min/1.73m2
 Low C3 > 6-8 minggu
 Recurrent hematuria
Streptozyme test

 Antistreptolysin (ASO) – false negative: pyoderma, prior antibiotic - >250 U

 Antihyaluronidase (AHase)
 Antistreptokinase (ASKase)
 Antinicotinamide-adenine dinucleotidase (anti-NAD)
 Anti-DNAse B antibodies

 Pyoderma – AHase dan anti-DNAase B

Complications

 Hypertension + CNS
 Anemia – dilution (ECF expansion)
 Pulmonary edema
 Congestive heart failure
 Low GFR
Follow-up

 Edema – hilang 5-10 days

 TD - 2-3 minggu
 Proteinuria – 2-6 bulan
 Gross hematuria - 1-3 minggu
 C3 concentration - 8-10 minggu
 Microscopic hematuria - 6 bulan

 Follow up 4 minggu 1x dalam 6 bulan, 6 bulan 1x dalam 6 bulan berikutnya

Kesimpulan

 Glomerulunefritis akut post streptococcus dimulai dengan infeksi pada faringitis atau kulit
pada anak-anak. Karena itu pemberian antibiotik secara adekuat dapat mencegah terjadinya
kerusakan pada membran basal ginjal.