Paediatric Clinical Guidelines
Renal 6.4
December 2004
THE INVESTIGATION AND MANAGEMENT OF
ACUTE GLOMERULONEPHRITIS IN CHILDREN
DATE:
REVIEW DATE:
AUTHOR:
JOB TITLE:
INFORMATION SOURCE:
December 2004
December 2007
Dr JHC Evans
Consultant Paediatric Nephrologist
Forfar and Arneil’s 5th edition
Medicines for Children, RCPCH, 1999
CLINICAL PATTERN of Acute nephritic syndrome
 Haematuria
 Oliguria
 Oedema
 Hypertension
 Proteinuria
Some patients may also have features of Nephrotic syndrome (see Policy 6.3)
Majority of cases are post-infectious, with group A -haemolytic streptococcus the most
common causative agent. Other important causes include IgA nephropathy, HSP nephritis
and lupus nephritis. Usually presents 1 – 2 weeks post URTI and sore throat. For
comprehensive list of aetiologies see Forfar & Arneil.
DIAGNOSIS:
Urinalysis:
Urine microscopy:
Usually macroscopic haematuria
Variable proteinuria
Should be done on fresh urine
Dysmorphic red cells and casts (red cell,
haemogranular and granular)
In mild case casts may be found only in centrifuged urine
Throat swab
Blood:
FBC and platelets:
Mild normochromic, normocytic anaemia common
Renal function tests: U&E, bicarb, creatinine, albumin,
calcium, phosphate, total protein
ASOTitre
Anti-DNAse B and Antihyaluronidase titres: should be done in
the absence of evidence of sore throat as ASOtitre
may not rise after streptococcal skin infection
C3, C3d, C4:
Usually low C3 normal C4
Autoantibody screen including ANA
Immunoglobulins
Renal USS
CXR: If hypertensive or fluid overloaded
In cases with evolving renal failure, nephrotic syndrome or clinical features suggestive
of systemic vasculitis would recommend discussion with paediatric renal team. In
these cases further investigations to consider:
General Viral titres plus Hep B and C, HIV, Hantavirus titres
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Paediatric Clinical Guidelines
Renal 6.4
December 2004
ANCA, Anti GBM, Cryoglobulin titre
MANAGEMENT:
Most children will need admission initially because of the presence of fluid retention,
oliguria, hypertension or worsening renal function.
INFECTION
10/7 Penicillin (Does not affect natural history but limits spread of nephritogenic strain)
Phenoxymethylpenicillin:
< 1 yr
62.5 mg qds
1 – 5 yr
125 mg qds
6 – 12 yr
250 mg qds
> 12 yr 500 mg qds
HYPERTENSION (i.e. BP >95% centile)
 Treat fluid overload (see below)
 Do not use an ACE Inhibitor (may worsen renal function)
 Refer to Hypertension policy 2.2 which also includes BP centile charts.
FLUID BALANCE
 Fluid balance should be closely monitored.
 All children should be weighed daily.
 All patients should be on a no added salt diet.
 If oliguric (<0.5 ml/kg/hr) will require fluid restriction to replacement of insensible
losses (400 ml/m2/day) + previous days urine output.
 If overloaded i.e. hypertensive, raised JVP, oedematous should give Frusemide 1 –
2 mg/kg up to twice daily, to induce a negative fluid balance.
CRITERIA FOR REFERAL TO PAEDIATRIC NEPHROLOGY
COMPLICATIONS IN THE ACUTE PHASE OF ILLNESS:
 Hyperkalaemia
 Uncontrolled hypertension
 Fluid overload unresponsive to diuretics
ATYPICAL FEATURES SUCH AS:
 Deteriorating renal function
 Nephrotic syndrome
 Features suggestive of systemic vasculitis
 Normal C3
 Low C4
 Positive antinuclear antibodies
 Low C3 at 3 months
 Persistence of proteinuria at 6 weeks
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Paediatric Clinical Guidelines
Renal 6.4
December 2004
INITIAL MANAGEMENT OF COMPLICATIONS
HYPERKALAEMIA
 All treatments to decrease serum potassium are temporary measures, prior to
dialysis.
 See Hyperkalaemia policy 10.11 for treatment.
HYPOCALCAEMIA
 If symptomatic:
 Under 5 years:
 Above 5 years:
10% Calcium gluconate 0.3 ml/kg iv over 5 – 10 mins.
Liquid calcium sandoz 0.5 ml/kg qds
Consider oral calcium carbonate which will also reduce
phosphate levels (calcichew 1 tds before meals)
ACIDOSIS
 Sodium bicarbonate can be given orally 2mmol/kg/dy in 4 divided doses.
SEIZURES
 Treat electrolyte disturbance or hypertension.
 Many anticonvulsants accumulate in renal failure. Benzodiazepines are the safest.
PROGNOSIS AND FOLLOW UP





95% of patients with post streptococcal nephritis will make a complete recovery.
However a small proportion will develop rapidly progressive glomerulonephritis.
If renal function is satisfactory and improving and the patient is normotensive an
early discharge should be possible.
Follow up should include a convalescent ASOTitre and repeat complement levels &
biochemistry at 3 months to ensure they return to normal.
Microscopic haematuria may persist for 1 – 2 years.
Children can be discharged from long term follow up once urinalysis, BP and
creatinine are all normal.
CONTACT NUMBERS
Consultant Paediatric Nephrologist on-call
Paediatric Nephrology SpR
Via City Hospital switchboard
46458 (Lambley Ward) or bleep via
City Hospital switchboard
AUDIT POINTS
1. Are investigations undertaken as per guidelines?
2. Are referrals made to paediatric nephrology appropriate and at correct time?
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Paediatric Clinical Guidelines
Renal 6.4
December 2004
PAEDIATRIC CLINICAL GUIDELINES
ISSUE:
VERSION: FINAL
Title: THE INVESTIGATION AND MANAGEMENT OF ACUTE
GLOMERULONEPHRITIS IN CHILDREN
Author:
Job Title:
Dr MT Christian
Consultant Paediatric Nephrologist
First Issued:
Date Revised: December 2004
Review Date: November 2007
Document Derivation:
References
Consultation Process:
Consultant Paediatric
Nephrologists
Paediatric Pharmacist
Cross town Paediatric Policy Group
Included in document
Ratified By:
Paediatric Protocols Committee
Chaired By:
Consultant with Responsibility: Dr Stephanie Smith
Distribution:
All wards QMC and CHN
Training issues: included in the Induction Programme
Audit:
included in the document
This guideline has been registered with Nottingham City Hospital NHS Trust and
QMC Clinical Guidelines Committee. However, clinical guidelines are ’guidelines’
only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or
expert. Caution is advised when using guidelines after the review date.
MANUAL AMENDMENTS RECORD
(Please complete when making any hand-written changes/ amendments to protocol and not processed
through protocol committee)
Date
16/12/04
Author
Martin Christian
Description
1. Additional sentence to first paragraph on causes of
acute nephritis.
2. Hypocalcaemia. Change <5’s to calcium sandoz from
calcium carbonate (agreed at committee)
3. Change in contact details to state consultant paediatric
nephrologist on-call
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