Glomerulonephritis also known as Glomerular Nephritis (GN) is a type of kidney disease that involves the glomeruli.

The glomeruli are very small, important structures in the kidneys that supply blood flow to the small units in the kidneys that filter urine, called the nephrons.

During glomerulonephritis, the glomeruli become inflamed and impair the kidney's ability to filter urine.

If the kidneys become affected in this way, they cannot work properly, which causes kidney disease. This can lead to: Proteinuria
Protein from your blood leaking into your urine

Hematuria
Red blood cells being detected in your urine

Waste products and fluid building up in your body

This can cause complications, such as high blood pressure (hypertension). If the kidneys are severely affected, they may no longer work. This is known as kidney failure.

Glomerulonephritis can be acute (a sudden attack of inflammation) or chronic (coming on gradually).

Glomerulonephritis may develop after a bacterial infection or streptococcal infection, like strep throat, or it may be caused by a chronic condition. This is called Acute Poststreptococcal Glomerulonephritis.

GLOMERULUS

Normal histological structure of a glomerulus. On the right, is a 3-D illustration of a glomerulus.

Left one shows AA = affrent arteriole, EA= Efferent arteriole, BC= Bowmans capsule, US= Urinary space

TYPES OF GLOMERULONEPHRITIS

There are several types of glomerulonephritis. However, the condition can be broadly split into two main types:
1. PRIMARY GLOMERULONEPHRITIS

2. SECONDARY GLOMUERULONEPHRITIS

Primary Glomerulonephritis develops on its own and is not related to another condition.
In most cases, the cause of primary Glomerulonephritis is unknown. However, in some cases, a specific cause can be found, such as a reaction to a viral infection or medication.

Secondary Glomerulonephritis develops as a result of another condition.

Conditions that can cause secondary Glomerulonephritis include: systemic lupus erythematosus Vasculitis These are autoimmune conditions. An autoimmune condition is where your immune system reacts abnormally. Instead of doing its usual job of fighting infection, it attacks your

CAUSES
In many cases, the exact cause of Glomerulonephritis is unknown. It is thought that the condition is often caused by the immune system, the bodys natural defense system against illness and infection.

The most common known causes are b acterial (most often streptococcal) and viral infections.

People with autoimmune disorders, such as lupus, also seem to be at risk of developing Glomerulonephritis. The immune system, instead of attacking bacteria or viruses, attacks the kidneys so that they can't function properly
Other systemic diseases may include: Polyarteritis nodosa group.
An inflammatory disease of the arteries.

Wegener vasculitis.
A progressive disease that leads to widespread inflammation of all of the organs in the body.

Henoch-Schnlein purpura.
A disease usually seen in children that is associated with purpura (small or large purple lesions on the skin and internally on the organs) and involves multiple organ systems.

A form of inherited Glomerulonephritis called Alport syndrome, which affects both men and women; men are more likely to have kidney problems. Treatment focuses on preventing and treating high blood pressure and preventing kidney damage.
In children, a common cause of Glomerulonephritis is from a streptococcal infection, such as strep throat or upper respiratory infection. Glomerulonephritis usually occurs more than one week after an infection.

(APSGN)

A type of Glomerulonephritis that develops after a bacterial infection or streptococcal infection, like strep throat, or it may be caused by a chronic condition. It is relatively common bilateral inflammation of the Glomeruli. It follows a streptococcal infection of the respiratory tract or, less often, a skin infection, such as impetigo. It is not an infection of the kidney but rather the result of an immune mechanism of the body. Characterized by sudden onset proteinuria and hematuria.

NURSING ASSESSMENT
Obtain history regarding recent streptococcal infection. Obtain appropriate cultures and assess for current infection. Measure urine output and degree of hematuria and proteinuria. Weigh child and document areas and extent of edema. Obtain baseline BP reading to assess for

PATHOPYSIOLOGY & ETHIOLOGY

ACUTE GLOMERULONEPHRITIS Antigen (group A beta-hemolytic streptococcus) Antigen-antibody product Deposition of antigen-antibody complex in the glomerulus

Increased production of epithelial cells lining the glomerulus Leukocytes infiltrate the glomerulus Thickening of the glomerular filtration membrane
Scarring and loss of glomerular filtration membrane Decreased glomerular filtration

RISK FACTORS
Most common in children between ages of 5 and 10 years. (The age group most susceptible to streptococcal
infections)

Boys appear to develop the disease more often than girls. Occurs more often during winter and spring.
The child has typically has a history of a recent respiratory infection (within 7 14 days) or impetigo
(within 3 weeks).

All children who have had strep throat, tonsillitis, otitis media, or impetigo caused by

CLINICAL MANIFESTATIONS Onset Usually 10 to 20 days after acute pharyngitis. In streptococcal skin infections, the latency period may be as long as 6 weeks. May be abrupt and severe, or mild and detected only by laboratory measures.

SIGNS AND SYMPTOMS

Urinary symptoms: oDecreased urine output oBloody or brown-colored urine, tea colored or smoky. Edema oPresent in most patients oUsually mild oCommonly manifested by periorbital edema in the morning oMay appear only as rapid weight gain oMay be generalized and influenced by posture

Hypertension
oPresent in more than 50% of patients o Usually mild oRise in blood pressure (BP) may be sudden oUsually appears during the first 4 to 5 days of the illness

Malaise
Mild headache

vomiting Abdominal pain

GI disturbances, especially anorexia and

Low grade fever

Acute poststreptococcal glomerulonephritis in an 8-year-old child who presented with tea-colored urine (A), bilateral periorbital edema (B), and hypertension following streptococcal pharyngitis

Tea-colored urine

DIAGNOSTIC EVALUATION

Urinalysis:
oDecreased output (oliguria)may approach anuria oMicroscopic or gross hematuria oSpecific gravitymoderately elevated oProteinuria may be mild to severe oMicroscopicred blood cells, leukocytes, epithelial cells, and casts oLow urinary sodium

Blood urea nitrogen (BUN) and creatinine usually mildly to moderately elevated; however, normal in 50% of patients

Antistreptolysin-O titerelevated Anti-DNase B titerelevated

Erythrocyte sedimentation rateelevated

Complement C3 and complement C4 depressed Chest X-raymay show pulmonary congestion, cardiac enlargement during the edematous phase

COMPLICATIONS
The following complications occur infrequently.

Hypertensive encephalopathy
refers to a relatively rapidly evolving syndrome of severe hypertension in association with severe headache, nausea, and vomiting, visual disturbances, convulsions, altered mental status and, in advanced cases, stupor and coma

Uremia
a state in which the blood urea nitrogen level, an indicator of nitrogen waste products, is elevated. In uremia, the kidneys failure to filter nitrogen waste properly leads to excessively high levels of nitrogen wastes in the bloodstream. Uremia is life-threatening because too much nitrogen in the blood is toxic to the body.

Heart failure
a progressive disorder in which damage to the heart causes weakening of the cardiovascular system. It manifests by fluid congestion or inadequate blood flow to tissues.

Anemia
refers to a deficit RBC or Hgb in the blood resulting in decreased oxygencarrying capacity.

NURSING DIAGNOSES Impaired Urinary Elimination related to Glomerular dysfunction Excess Fluid Volume related to impaired renal function Deficient diversional Activity related to focus on fluid and salt restriction Deficient knowledge regarding Acute Glomerulonephritis and its management

THERAPEUTIC MANAGEMENT
Antibiotic therapy may be initiated if there is any concern that streptococci or other organisms are still present.
Other management is mostly symptomatic; in most patients, spontaneous recovery is expected. Hospitalization is usually not necessary. Salt and fluid intake should be restricted during the acute phase of the disease. Diuretics (promotes the formation of urine by the kidney) should be administered if significant edema or hypertension develops. A renal biopsy (is the removal of a small piece of kidney tissue for examination) may be indicated if the child does not recover from

NURSING INTERVENTIONS Promoting Normal Urine Output Monitor daily intake and output. Test and record urine for hematuria and proteinuria as directed. Note color of urine. Monitor daily weight.

Reducing Excess Fluid Volume

Provide a no-added-salt diet during the acute phase of the illness. Other restrictions may be indicated if renal function is impaired. Protein intake is not usually restricted because of the possible risk of malnutrition.
Restrict fluids in children with hypertension, edema, heart failure, or renal failure.

Place a sign that indicates dietary restrictions on the child's bed so that staff and visitors will be aware of special needs. With fluid restrictions, offer small amounts of fluids spaced at regular intervals throughout the day and evening. Use an appropriate size of cup for the amount of fluid being offered. Check BP, as ordered or needed, and observe for signs of hypertension. Administer antihypertensive drugs as

Promoting Diversional Activity

Explain fluid restriction at an age-appropriate level and direct the child's focus away from restrictions.
Provide the child with diversional activity and play therapy. Encourage activity as tolerated.

Providing Information
Explain all aspects of the diagnostic tests and treatment in terms the family can understand. Explain the purpose of all medications and the restricted diet, including a review of high-sodium foods to avoid and sample menus. Encourage family participation in the child's care. Help the family plan for adaptation of the child's nursing care to the home environment.

Arrange for appointments for continued medical supervision and initiate referrals when appropriate.

Family Education and Health Maintenance

Reinforce medical explanation of the disease process. oEmphasize the need for medical evaluation and culture of all sore throats for all family members. oAlert the family to signs and symptoms of disease recurrence. oBe aware that microscopic hematuria may persist up to 1 year.
Reinforce activity recommendation; usually not restricted.

Advise that tonsillectomy or other oral surgery is not recommended for several months after the acute phase of glomerulonephritis. o If this type of surgery is necessary, penicillin may be recommended before and after the procedure to prevent bacterial infection. o Obtain information regarding drug allergies before administering penicillin.

OUTCOME EVALUTION
Output remains adequate. Weight returns to baseline.

Child does age-appropriate activities as tolerated and does not complain of thirst Parents and child can state rationale for treatment.

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