How is acute glomerulonephritis treated in children?

The main directions in the treatment of acute glomerulonephritis in children are as follows:

• The regime of physical activity.
• Dietotherapy.
• Symptomatic therapy:
  • About antibacterial therapy;
  • O diuretic drugs;
  • About antihypertensives.
• Pathogenetic therapy.
• Effects on the processes of microthrombosis:
  • anticoagulant drugs;
  • antiaggregant drugs.
• Effects on immune inflammation:
  • glucocorticoid drugs;
  • cytostatic drugs.

[1], [2], [3], [4], [5], [6], [7]

Physical activity

Bed rest is prescribed for 7-10 days only for conditions associated with the risk of complications: heart failure, angiospastic encephalopathy, acute renal failure. Prolonged strict bed rest is not indicated, especially with nephrotic syndrome, as the threat of thromboembolism increases. The expansion of the regimen is allowed after the normalization of blood pressure, a decrease in edematous syndrome and a decrease in the hematuria.

Diet for acute glomerulonephritis in children

Assignable table - kidney number 7: low-protein, low-sodium, normocaloric.

The protein is limited (to 1-1.2 g / kg due to the restriction of proteins of animal origin) to patients with impaired renal function with an increase in the concentration of urea and creatinine. In patients with NS, the protein is prescribed according to the age norm. Limitation of protein is carried out for 2-4 weeks before the normalization of urea and creatinine. With a salt-free diet number 7, the food is prepared without salt. In the products included in the diet, the patient receives about 400 mg of sodium chloride. With the normalization of hypertension and the disappearance of edema, the amount of sodium chloride is increased by 1 g per week, gradually adjusting to normal.

Diet № 7 has a high energy value - not less than 2800 kcal / day.

The amount of injected fluid is regulated, guided by the diuresis of the previous day, taking into account extrarenal losses (vomiting, loose stools) and perspiration (500 ml for school-age children). In a special restriction of the fluid is not necessary, since there is no thirst against the background of a salt-free diet.

To correct hypokalemia appoint products that contain potassium: raisins, dried apricots, prunes, baked potatoes.

Table number 7 is prescribed for a long time with acute glomerulonephritis - for the entire period of active manifestations with a gradual and slow expansion of the diet.

In acute glomerulonephritis with isolated hematuria and preservation of kidney function, dietary restrictions are not applied. Assign table number 5.

[8], [9], [10], [11], [12]

Symptomatic treatment of acute glomerulonephritis in children

Antibiotic therapy

Antibiotic therapy is carried out by patients from the first days of the disease when referring to a previous streptococcal infection. Preference is given to antibiotics of the penicillin series (benzylpenicillin, augmentin, amoxiclav), less often macrolides or cephalosporins are prescribed. Duration of treatment - 2-4 weeks (amoxicillin inside 30 mg / (kghsut) in 2-3 doses, amoksiklav inside 20-40 mg / (kghsut) in three doses).

Antiviral therapy is indicated if its etiological role is proven. Thus, in association with the hepatitis B virus, the appointment of acyclovir or valaciclovir (valtrex) is indicated.

[13], [14], [15], [16], [17]

Treatment of edematous syndrome

Furosemide (lasix) is referred to as loop diuretics, which block potassium-sodium transport at the level of the distal tubule. Assign inside or parenterally from 1-2 mg / kg to 3-5 mg / (kghsut). With parenteral administration, the effect occurs 3-5 minutes later, with oral administration after 30-60 minutes. The duration of action for intramuscular and intravenous administration is 5-6 hours, with oral administration - up to 8 hours. Course from 1-2 to 10-14 days.

Hydrochlorothiazide - 1 mg / (kghsut) (usually 25-50 mg / day, starting with minimal doses). Breaks between receptions - 3-4 days.

Spironolactone (veroshpiron) is a sodium-preserving diuretic, an antagonist of aldosterone. Assign a dose of 1-3 mg / kg per day in 2-3 times. Diuretic effect - after 2-3 days.

Osmotic diuretics (polyglukin, reopoliglyukin, albumin) are prescribed for patients with refractory edema with nephrotic syndrome, with severe hypoalbuminemia. As a rule, combined therapy is used: a 10-20% albumin solution at a dose of 0.5-1 g / kg per reception, which is administered for 30-60 minutes, followed by administration of furosemide at a dose of 1-2 mg / kg and higher for 60 minutes in a 10% glucose solution. Instead of albumin, a solution of polyglucin or rheopolyglucin can be administered from a calculation of 5-10 ml / kg.

Osmotic diuretics are contraindicated in patients with OGN with nephritic syndrome, because they have hypervolemia and complications in the form of acute left ventricular failure and eclampsia.

Treatment of arterial hypertension

AH in ONS is associated with sodium and water retention, with hypervolemia, so in many cases, BP decrease achieves salt-free diet, bed rest and furosemide administration. The dose of furosemide can reach 10 mg / kg per day for hypertensive encephalopathy.

With CGN and, more rarely, with acute glomerulonephritis, hypotensive drugs are used in children.

Blockers of slow calcium channels (nifedipine under the tongue 0.25-0.5 mgDkgsut) in 2-3 times before the normalization of blood pressure, amlodipine inside 2.5-5 mg once a day before the normalization of blood pressure).

Angiotensin converting enzyme (ACE inhibitors): enalapril inside 5-10 mg / day in 2 doses, prior to the normalization of blood pressure, captopril inside 0.5-1 mgDkgsut) in the 3rd dose, before the normalization of blood pressure. Course - 7-10 days or more.

Simultaneous use of these drugs is undesirable, since the contractility of the myocardium can decrease.

Pathogenetic treatment of acute glomerulonephritis in children

Effects on microthromogenesis processes

Heparin sodium has a multifactorial effect:

• suppresses intravascular processes, including intra-cerebral coagulation;
• has a diuretic and natriuretic effect (suppresses aldosterone production);
• Has antihypertensive effect (reduces production of vasoconstrictor endothelin mesangial cells);
• has an antiproteinuric effect (restores a negative charge on BM).

Heparin sodium is administered subcutaneously in a dose of 150-250 IU / kghsut) in 3-4 doses. Course - 6-8 weeks. The cancellation of sodium heparin is carried out gradually by reducing the dose by 500-1000 IU per day.

Dipyridamole (quarantil):

• has antiaggregant and antithrombotic effect. The mechanism of action of quarantil is associated with an increase in the content of cAMP in platelets, which prevents their adhesion and aggregation;
• stimulates the production of prostacyclin (a powerful antiaggregant and vasodilator);
• reduces proteinuria and hematuria, has an antioxidant effect.

Curantil is prescribed in a dose of 3-5 mg / kghsut) for a long time - for 4-8 weeks. Assign in the form of monotherapy and in combination with sodium heparin, glucocorticoids.

[18]

Impact on the processes of immune inflammation - immunosuppressive therapy

Glcocorticoids (HA) are non-selective immunosuppressants (prednisolone, methylprednisolone):

• have anti-inflammatory and immunosuppressive effect, reducing the influx of inflammatory (neutrophils) and immune (macrophages) cells in the glomeruli, and thereby inhibit the development of inflammation;
• suppress the activation of T-lymphocytes (as a result of a decrease in IL-2 production);
• reduce the formation, proliferation and functional activity of various subpopulations of T-lymphocytes.

Depending on the response to hormone therapy, hormone-sensitive, hormone-resistant and hormone-dependent variants of glomerulonephritis are isolated.

Prednisolone is prescribed according to the schemes depending on the clinical and morphological variant of glomerulonephritis. In acute glomerulonephritis in children with HC, prednisolone is administered internally at a rate of 2 mg / kg x-ray) (not more than 60 mg) continuously for 4-6 weeks, in the absence of remission, up to 6-8 weeks. Then they switch to an alternating course (every other day) at a dose of 1.5 mg / kghs) or 2/3 of the treatment dose in one morning in the course of 6-8 weeks, followed by a slow decrease of 5 mg per week.

With a steroid-sensitive HC, the subsequent relapse is treated with prednisolone at a dose of 2 mg / kght) until three normal results of the 24-hour urine analysis are obtained, followed by an alternating course for 6-8 weeks.

With often relapsing and hormone-dependent NS, treatment with prednisolone in a standard dose or pulse therapy with methylprednisolone at a dose of 30 mg / kghs) is started intravenously three times at a one-day interval for 1-2 weeks, followed by a transition to prednisolone daily, and then to an alternating course. With often recurrent HC after 3-4 relapses, the appointment of cytostatic therapy is possible.

Cytotoxic drugs are used in chronic glomerulonephritis: mixed form and nephrotic form with frequent relapses or with hormone-dependent variant.

• Chlorambucil (leukeran) is prescribed in a dose of 0.2 mgDkgsut) for two months.
• Cyclophosphamide: 10-20 mg / kg per injection in the form of pulse therapy once every three months or 2 mg Dkgsut) for 8-12 weeks.
• Cyclosporine: 5-6 mg / kg xut) for 12 months.
• Mycophenolate mofetil: 800 mg / m2 6-12 months.

Cytotoxic drugs are prescribed in combination with prednisolone. The choice of therapy, the combination of drugs and its duration depend on the clinical, morphological and flow characteristics.

Depending on the clinical variant and the acute and morphological variant of chronic glomerulonephritis, appropriate treatment regimens are chosen.

We give possible treatment regimens. In acute glomerulonephritis with nephritic syndrome, the appointment of antibiotic therapy for 14 days, diuretic drugs, antihypertensive drugs, as well as curantyl and heparin sodium.

In acute glomerulonephritis in children with nephrotic syndrome, the appointment of diuretic drugs (furosemide in combination with osmotic diuretics) and prednisolone according to the standard scheme is indicated.

With OGN with isolated urinary syndrome: antibiotics according to indications, quarantil and in some cases heparin sodium.

In acute glomerulonephritis in children with AH and hematuria: diuretic, hypotensive drugs, prednisolone according to the standard scheme and in the absence of effect - the connection of cytostatics after a kidney biopsy.

In CGN (nephrotic form), pathogenetic therapy includes the appointment of prednisolone, diuretic drugs, quarantil, heparin sodium. However, with frequently recurring course or hormone resistance, cytotoxic drugs should be used. The scheme and duration of their application depends on the morphological variant of glomerulonephritis.

When CGN (mixed form) with exacerbation and the presence of edema, diuretics and antihypertensive drugs are prescribed, as prednisolone in the form of pulse therapy with cyclosporine connection as an immunosuppressive therapy.

Treatment of complications of acute glomerulonephritis in children

Hypertensive encephalopathy:

• intravenous administration of furosemide in high doses - up to 10 mg / kght);
• intravenous sodium nitroprusside 0.5-10 μg / (kghmin) or nifedipine under the tongue 0.25-0.5 mg / kg every 4-6 hours;
• with convulsive syndrome: 1% solution of diazepam (seduksena) intravenously or intramuscularly.

Acute kidney failure:

• furosemide up to 10 mg / kght);
• infusion therapy with 20-30% glucose solution in small volumes of 300-400 ml / day;
• with giperkaliemii - intravenous calcium gluconate in a dose of 10-30 ml / day;
• introduction of sodium bicarbonate in a dose of 0.12-0.15 g of dry matter inwards or in enemas.

With the increase of azotemia above 20-24 mmol / l, potassium above 7 mmol / l, a pH lower than 7.25 and anuria of 24 hours, hemodialysis is indicated.

Edema of the lung:

• furosemide intravenously up to 5-10 mg / kg;
• 2.4% solution of euphyllin intravenously 5-10 ml;
• Korglikon intravenously 0.1 ml per year of life.

Forecast

Acute glomerulonephritis in children has a favorable prognosis. Recovery is observed in 85-90% of cases. The lethal outcome is rare (less than 1%).

[19], [20], [21], [22],

Further management

Clinical follow-up is mandatory for 5 years.