Treatment and prevention of acute poststreptococcal glomerulonephritis

Treatment of acute poststreptococcal glomerulonephritis consists of the following:

• Impact on the etiological factor - streptococcal infection (patients and their relatives).
• Normalization of blood pressure, reduction of swelling.
• Maintaining water and electrolyte balance.
• Treatment of complications (encephalopathy, hyperkalemia, pulmonary edema, acute renal failure).
• Immunosuppressive therapy - for nephrotic syndrome and protracted course.

Given the connection between acute nephritis and streptococcal infection, treatment of acute post-streptococcal glomerulonephritis requires the administration of an antibiotic from the penicillin group in the first days of the disease (for example, phenoxymethylpenicillin - 125 mg every 6 hours for 7-10 days) and, in case of allergy to them, erythromycin (250 mg every 6 hours for 7-10 days). Such therapy is primarily indicated if the disease occurs after pharyngitis, tonsillitis, skin lesions, especially with positive results of skin and throat cultures, as well as with high titers of antistreptococcal antibodies in the blood. Long-term antibacterial treatment of acute post-streptococcal glomerulonephritis is necessary in the development of acute nephritis in the context of sepsis, including septic endocarditis.

Acute poststreptococcal glomerulonephritis - regimen and diet

In the first 3-4 weeks of illness, in case of large edema, macrohematuria, high hypertension and heart failure, it is necessary to strictly adhere to bed rest.

In the acute phase of the disease, especially with pronounced signs of nephritis (rapid onset with edema, oliguria and arterial hypertension), it is necessary to sharply limit the consumption of sodium (up to 1-2 g/day) and water. In the first 24 hours, it is recommended to completely stop taking liquids, which in itself can lead to a decrease in edema. Subsequently, liquid intake should not exceed its excretion. Limiting sodium and water reduces the volume of extracellular fluid, which helps treat arterial hypertension. With a significant decrease in CF, oliguria, it is advisable to limit protein intake [up to 0.5 g/kg/day)].

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Treatment of edema in acute poststreptococcal glomerulonephritis

Because of the primary fluid retention that contributes to the development of edema in acute poststreptococcal glomerulonephritis, treatment of acute poststreptococcal glomerulonephritis involves restricting sodium and water:

• hypothiazide 50-100 mg/day (ineffective with a significant decrease in CF);
• furosemide 80-120 mg/day (effective even with reduced CF);
• Spironolactones and triamterene are not used due to the risk of developing hyperkalemia.

Pulmonary edema, which complicates the course of acute nephritic syndrome, is usually a consequence of hypervolemia caused by sodium and water retention, and not heart failure. In this case, digitalis is ineffective and can cause intoxication.

Treatment of acute poststreptococcal glomerulonephritis includes sodium and water restriction, potent loop diuretics, morphine, and oxygen.

Treatment of arterial hypertension in acute poststreptococcal glomerulonephritis

• A sodium- and water-restricted diet, bed rest, and the use of diuretics (furosemide) usually control moderate hypertension (diastolic BP <100 mm Hg). Diuretics as a component of antihypertensive therapy reduce the need for other antihypertensive drugs.
• Vasodilators - calcium channel blockers (nifedipine 10 mg repeatedly during the day) are preferable for more severe and persistent hypertension.
• ACE inhibitors are used with caution due to the risk of hyperkalemia.
• Furosemide in large doses, intravenous hydralazine, sodium nitroprusside, diazoxide are required as emergency measures for hypertensive encephalopathy (intractable headache, nausea, vomiting) due to cerebral edema.
• Diazepam (unlike other anticonvulsants, it is metabolized in the liver and is not excreted by the kidneys) parenterally, intubation if necessary - if convulsive syndrome develops.

Acute renal failure and acute poststreptococcal glomerulonephritis

Long-term oliguria in acute poststreptococcal polymerulonephritis occurs in 5-10% of patients.

Treatment of acute poststreptococcal glomerulonephritis in these cases includes a sharp restriction of sodium and water, potassium and protein in the diet. With increasing azotemia and especially hyperkalemia, hemodialysis is indicated.

Moderate hyperkalemia in acute poststreptococcal hypermerulonephritis is often observed; in case of severe hyperkalemia, emergency measures must be taken:

• furosemide in high doses to stimulate kaliuresis;
• intravenous insulin, glucose, calcium and sodium bicarbonate;
• emergency hemodialysis in case of development of life-threatening hyperkalemia.

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Immunosuppressant therapy and acute poststreptococcal glomerulonephritis

• For patients with associated and long-term nephrotic syndrome (more than 2 weeks), an increase in creatinine levels that does not tend to increase further, but also does not return to normal, and if a kidney biopsy cannot be performed, prednisolone is indicated [1 mg/kg/day].
• Patients with rapidly progressive renal failure require a renal biopsy. If crescents are found, a short course of methylprednisolone pulse therapy (500-1000 mg intravenously daily for 3-5 days) is recommended.

Prevention of acute poststreptococcal glomerulonephritis

A particular problem is the diagnosis of streptococcal pharyngitis in patients without nephritis who complain of sore throat. Since only 10-15% of all infectious diseases of the pharynx in adults are caused by streptococcus, and when isolating a streptococcus culture from the pharynx, 10% of false negative and 30-50% of false positive results are obtained (especially in streptococcus carriers), the following clinical approach can be used to decide on the appointment of antibiotics.

Fever, enlarged tonsils, and cervical lymph nodes are more common in streptococcal infections, and the absence of these three symptoms makes streptococcal infection unlikely. Because of the high rate of false-positive and false-negative results of bacteriological isolation of streptococcal culture from the throat, antibiotics should be prescribed to all patients with the clinical triad of fever, enlarged tonsils, and cervical lymph nodes. In the absence of all these symptoms, antibiotic therapy is not indicated, regardless of the results of bacteriological testing. In the presence of individual symptoms, antibiotics are prescribed if positive results of bacteriological testing are obtained.

Since relatives of patients with acute post-streptococcal glomerulonephritis in most cases show evidence of streptococcal infection within 2-3 weeks and more than 1/3 develop nephritis, preventive treatment of acute post-streptococcal glomerulonephritis with antibiotics for relatives and other people at risk of infection is justified during epidemics.