Glomerulonephritis in children is a syndrome of heterogeneous diseases that affect the glomeruli of the kidneys or nephrons, which are the main building block of this organ. It manifests itself with hematuria, proteinuria, facial swelling and problems with urination. The disease can occur in acute or chronic form. Consider what glomerulonephritis is, symptoms and treatment in children.
What is glomerulonephritis in children?
The kidneys are a paired organ responsible for the excretion of waste, water and electrolytes (potassium, sodium, calcium) from the body through urine. Their acute or chronic damage leads to a temporary or permanent deterioration in activity.
The main link of the kidneys responsible for filtration activity (purification) are glomeruli (glomeruli of the kidneys). The main component of the glomeruli is their membrane, which is designed to filter blood and remove accumulated substances and water in the urine. In the case of normal kidney function, the filtering membrane retains all the necessary ingredients in the human blood, including protein, so there is no normal protein in the urine analysis.
Glomerulonephritis is a group of diseases that are based on damage to the glomerular filtration membrane, which begins to pass protein and red blood cells into the urine. This may be due to viral or bacterial infections. The disease may also have a genetic background. This can occur in an acute, short-term manner, usually associated with infections (for example, after streptococcal pharyngitis) or in a chronic manner, which in some cases leads to irreversible damage to the kidneys.
Types of Glomerulonephritis
The following types of this disease are distinguished:
- hematuric - hematuria and arterial hypertension are observed;
- nephrotic - hydrothorax appears, pronounced edema;
- hypertonic - increased pressure is observed;
- combined - combines all the symptoms of the above forms;
- latent (latent) - with no symptoms.
The latent form of the disease is more dangerous, since its asymptomatic course can last 10-15 years. Its detection is possible either by chance on the analysis of urine, or with the development of complications. It has a favorable prognosis with timely treatment. Hematuric glomerulonephritis in children, as well as nephrotic type of the disease, have a relatively unfavorable outcome. With the acute form and early diagnosis and adequate therapy, a complete recovery is possible. If no medical measures are taken within six months or an incorrect treatment regimen is applied, the process goes into a chronic form. The treatment standards for acute glomerulonephritis in children differ from the treatment methods used in the chronic form of the disease. In the latter case, the therapy will be longer, complicated and expensive, and the prognosis will be less reassuring.
What is acute glomerulonephritis and what are its causes?
Compared with adults, children are more likely to suffer from acute glomerulonephritis. Pathology is more common in boys than in girls. The peak incidence occurs at school age (7-10 years), children under 3 years old rarely get sick. Acute glomerulonephritis accounts for about 10-15% of all types of glomerulonephritis and occurs in the amount of 2-5 cases per 100,000 children per year.
The most common acute glomerulonephritis is preceded by an infection of the upper respiratory tract or skin. The main role in the formation of the acute form of the disease is played by immune complexes (the body's response to infection), which damage the glomerular filtration membrane, which leads to the appearance of protein and red blood cells in the urine.
How does acute glomerulonephritis manifest
Most often, the disease begins with the appearance of edema located on the face (swollen eyes after sleep) or around the ankles on the legs, as well as hematuria. Urine may be red or dark brown. Children usually do not have a fever during this period. These changes appear 5-21 days after inflammation of the throat and upper respiratory tract or 3-4 weeks after dermatitis. Edema occurs in almost all patients. It can persist up to two weeks after the onset of the disease and is associated with a delay in water and sodium in the body. The child complains of abdominal pain, vomiting, headache, apathy appears, appetite worsens. These changes are often accompanied by hypertension.
In rare cases, with significantly increased blood pressure, the so-called hypertensive crisis with seizures may occur. In some cases, there is a significant decrease in the amount of urine, up to the occurrence of acute renal failure, including anuria. If the color of the urine changes, swelling of the face or ankle appears, immediately consult a doctor to make the correct diagnosis and treatment of glomerulonephritis in children.
How is a doctor diagnosed?
Laboratory research:
The main laboratory test is a urinalysis, which should always be done if acute glomerulonephritis is suspected. Characteristic abnormalities in this study:
- microscopic bleeding (that is, the presence of red blood cells in the urine in an amount not visible to the naked eye, but detected by microscopic examination), which is a constant symptom of the disease;
- proteinuria - the amount of protein lost in the urine during the day, usually does not exceed 3 g;
- the presence of white blood cells (rarely observed).
A blood test shows:
- decreased complement component C3 and complement hemolytic activity (CH50);
- increase in ASO titer (antistreptolysin O) above 200 IU;
- moderately severe anemia;
- in half the cases, an increase in the concentration of immunoglobulin IgG.
When observing the above-mentioned deviations in studies in children with glomerulonephritis, treatment and medical examination are carried out under the supervision of a nephrologist.
If acute glomerulonephritis is suspected in a hospital setting, blood pressure should be measured, and then repeated monitoring of its jumps 3-4 times a day. Ultrasound scanning of the kidneys usually does not show characteristic changes. In the vast majority of cases, there is no need for a kidney biopsy. A biopsy is carried out only with prolonged excretion of a small amount of urine for differentiation with acute renal failure or rapidly progressive glomerulonephritis.
Treatment of acute glomerulonephritis in children
Treatment of the acute form of the disease is symptomatic and is usually carried out in a hospital. It is necessary to provide the patient with rest and rest. Treatment in children of glomerulonephritis also consists in getting rid of arterial hypertension and diuretic hypertension.
Antibiotic therapy is indicated for the development of acute glomerulonephritis with pharyngitis, tonsillitis, skin lesions, especially with positive results of cultures with throat or with high titers of antistreptococcal antibodies in the blood.
Treatment of acute post-streptococcal glomerulonephritis in children is carried out with antibiotics from the penicillin group, cephalosporins for 10 days.
If proteinuria is high, the child is injected with a 20% solution of human albumin. When a child does not urinate for a long time and swelling increases, doctors may consider the possibility of renal replacement therapy (dialysis). After discharge from the hospital, a periodic urinalysis should be performed (once every two weeks). In case of prolonged observation of changes in the urine (hematuria, proteinuria), it is necessary to contact a pediatric nephrologist.
Is it possible to fully recover?
Acute glomerulonephritis is a serious disease, but with a good prognosis. Most symptoms completely disappear within a few weeks or months. With the correct treatment of acute glomerulonephritis in children, relapses of the disease are rare. However, keep in mind periodic urinalysis (once a quarter) and blood pressure measurements. For at least one year after acute glomerulonephritis, the child should be under the supervision of a nephrologist.
What is chronic glomerulonephritis and what are its causes
The cause of chronic forms of glomerulonephritis is a violation of the child’s immune mechanism. As a result of the body's response to infection, antibodies are formed against glomerular antigens and immunological deposits, which accumulate in blood vessels or kidneys and damage the membrane. Chronic glomerulonephritis can be a primary disease (applies only to the kidneys) or secondary to lesions in other organs (eg, viral hepatitis, systemic diseases, cancer). In childhood, chronic glomerulonephritis predominates. In children, the symptoms, causes, treatment of the disease are very diverse and depend on the type of glomerular inflammation. Most patients have proteinuria, hematuria and edema. In some cases, a relapse occurs, for example, caused by an infection of the upper respiratory tract.
The diagnosis of certain types of glomerulonephritis depends only on a kidney biopsy. This is important because different types of disease can occur with similar symptoms, and the specific treatment of the disease depends on its form.
How is chronic glomerulonephritis manifested?
Glomerulonephritis is most often manifested by proteinuria and edema, sometimes with hematuria. The onset of the disease can be secretive without any visible clinical symptoms. The child may be lethargic, complaining of a lack of appetite. Edema may appear on the face near the eyes, especially after sleep, on the legs around the ankles or swelling that is visible throughout the child’s body. The child quickly gains weight, despite a poor appetite. Edema can be detected by pressing the child’s foot around the ankle. When it is swollen, the "dimple" remains after pressure - small with slight swelling and deeper with large swelling.
In children from 1 to 12 years old, the most common type of disease is the so-called idiopathic nephrotic syndrome. It occurs with a frequency of 2-7 cases per year per 100,000 children. In young children, the probability of the onset of the disease in boys is 2-3 times higher than in girls. Most cases are recorded up to six years. A typical feature of idiopathic nephrotic syndrome is its relapse. If edema occurs (for example, difficulties in putting on shoes, rapid weight gain), you must urgently consult a doctor to make the correct diagnosis, and if glomerulonephritis is confirmed in children, it is the doctor who should prescribe the treatment according to the type of disease.
Diagnostics
The main study is urinalysis. If protein is found in the urine, it is necessary to repeat the test again after 1-2 days to assess whether protein loss is increasing. As directed by a physician, daily urine collection may be required. This is done by collecting each portion of urine 24 hours a day and pouring it into a container to evaluate how much protein the baby is losing. If protein excretion is found to exceed 50 mg / kg / day, nephrotic proteinuria is observed. Blood tests should evaluate the concentration of albumin, total protein, urea, creatinine, calcium, cholesterol. The blood coagulation system should also be evaluated as the onset of nephrotic syndrome predisposing to thrombosis, which can lead to embolism in the blood vessels.
Basic Examination - Kidney Biopsy
A kidney biopsy involves taking a small portion of the affected kidney. In older children (from 6 to 7 years), the procedure is performed under local anesthesia under the supervision of an ultrasound scan. The child should pass it on an empty stomach. Before the procedure, it is necessary to conduct a blood coagulation test. A biopsy can only be performed in children vaccinated with hepatitis B (after titration of antibodies). If the antibody titer is lower than protective, parents should vaccinate the child against hepatitis B. In the case of young children (under 6 years old), anesthesia must be performed to excise a piece of tissue from the kidney.
Before conducting a biopsy test, the child’s parents are asked to agree to the proposed examination. Like any invasive procedure, a small percentage of the kidney biopsy is burdened with complications, mainly bleeding and the formation of a hematoma around the kidney. After a biopsy, the child should lie on his back for the next 12 hours to reduce the risk of hematoma.
Most children with the first manifestation of nephrotic syndrome do not need to perform a kidney biopsy. This means that under a microscope, the structure of the kidney can look right without deviations.
In addition, there are indications for a biopsy when:
- atypical age of the child at the time of the disease (younger than 1 year or older than 12 years);
- treatment-resistant nephrotic syndrome;
- the need to verify changes in the parenchyma after prolonged treatment and with deterioration of renal function.
Treatment of chronic glomerulonephritis in children
Treatment is usually started at the hospital. In the case of nephrotic syndrome with large edema, glucocorticosteroids (methylprednisolone) are administered intravenously. Prednisone is used orally if protein loss is small and is not accompanied by severe edema.
A widely recognized standard in the treatment of first-line nephrotic syndrome is a 6-month course of glucocorticoid therapy in decreasing doses. These regimens are modified in case of steroid dependence or resistance. As in cases of relapse, steroid dependence, and resistance in children with glomerulonephritis, in the treatment, the drugs are changed to others such as Cyclophosphamide - up to 3 months, Chlorambucil - administered for up to 3 months, cyclosporin-A is used for years or mycophenolate mofetil - at least one year.
In addition to the main treatment (glucocorticosteroids), symptomatic treatment is performed to eliminate the disorders resulting from strong proteinuria. In case of significant protein losses with a decrease in the concentration of albumin in the blood, intravenous infusions of a 20% solution of albumin with diuretic therapy (furosemide) are administered. Diuretic treatment is performed in patients with edema with equalization of calcium in the blood, lowering cholesterol (statins), anticoagulant prophylaxis and treatment of hypertension, if it is detected. With a reduced amount of calcium, calcium and vitamin D3 are introduced. After the disappearance of the symptoms of proteinuria, further treatment can be carried out at home.
Clinical recommendations for the treatment of glomerulonephritis in children:
- Reducing the dose of the drug or its complete cessation (without prior approval from the doctor) can be extremely harmful. This can lead to relapse, re-hospitalization and intravenous treatment. This applies primarily to prednisone, cyclosporin A or mycophenolate mofetil.
- The basic rule of treatment for children with glomerulonephritis who need long-term therapy is the absolute observance of the doctor's recommendations.
Children must undergo specialized nephrological care with periodic monitoring in the outpatient department of nephrology. During the treatment of glomerulonephritis in children at home, a periodic urinalysis is required (general examination). If you develop new edema, immediately check your urine, evaluate proteinuria, and consult your doctor or children's treatment center. It should be remembered that even a banal infection can provoke a relapse of the nephrotic syndrome (including untreated teeth with inflammation), that is, the reappearance of edema and a decrease in the amount of urine. Then it is necessary to limit the flow of fluid to prevent swelling.
Children during treatment with high doses of glucocorticoids and immunosuppressive therapy should avoid all kinds of infections. In case of vaccinations, do not forget to use preparations containing live microorganisms. The use of high doses of glucocorticoids and immunosuppressants can reduce the effectiveness of the vaccine, and the vaccination itself can cause a relapse. The introduction of a basic vaccination calendar is difficult and each time requires a consultation with a nephrologist.
Most of the complications arising from nephrotic syndrome are associated with prolonged treatment with glucocorticoids (short stature, obesity, diabetes, cataracts, changes in bone density) or are the result of significant loss of protein in the urine (hypercoagulation, hypocalcemia, hypercholesterolemia).
Remissions and relapses
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Glomerulonephritis can also be a congenital disease. Sometimes it is severe and appears immediately after birth. Babies are usually born prematurely, with a large stomach and muscle weakness. As a result of very large losses of protein in the urine, increased edema develops and the risk of thrombotic complications and infections increases. If it is not possible to control protein loss, it is necessary to remove both kidneys and begin treatment with dialysis (usually peritoneal dialysis). After reaching a weight of 7-8 kg, a kidney transplant can be performed. In some cases of genetically determined nephrotic syndromes, the course is not so dramatic. Symptoms can occur at different ages and are similar to the symptoms found with other types of glomerulonephritis, that is, edema, proteinuria, etc. A common feature of genetic nephrotic syndrome is resistance to the applied causal treatment.
Now you know how the symptoms and treatment of glomerulonephritis occur in children, and what could be the consequences of improperly conducted therapy for the patient.