Initial Management of Post-Streptococcal Glomerulonephritis (PSGN)
The initial management of Post-Streptococcal Glomerulonephritis (PSGN) primarily consists of supportive care, antibiotic therapy to eliminate remaining streptococcal organisms, and targeted treatment of complications such as hypertension and fluid overload. 1
Antibiotic Treatment
- Penicillin or erythromycin (if penicillin-allergic) for 10 days is recommended to eliminate any remaining streptococcal organisms 1
- This treatment does not alter the course of established PSGN but prevents spread to others and reduces the risk of rheumatic fever
Supportive Care Measures
Fluid and Sodium Management
- Restrict sodium intake (<2.0 g/day) to help control edema and hypertension 1
- Implement fluid restriction in patients with significant edema or hypertension
- Monitor for signs of volume overload (pulmonary congestion, peripheral edema)
Blood Pressure Control
- Hypertension occurs in up to 95% of patients in the acute phase but is typically mild and short-term 2
- First-line treatment: Loop diuretics (primarily furosemide) to manage both hypertension and edema 2
- For persistent hypertension: Consider ACE inhibitors or ARBs at maximally tolerated doses 1
- Target systolic BP <120 mmHg in most adult patients 1
- Most patients normalize blood pressure within 3-5 days as glomerular filtration rate improves and edema resolves 2
Monitoring Parameters
- Daily weight measurements
- Strict intake and output monitoring
- Regular blood pressure checks
- Renal function tests (BUN, creatinine)
- Electrolytes (particularly potassium and sodium)
- Urinalysis to track hematuria and proteinuria
Management of Complications
Severe Hypertension
- Treat aggressively to prevent hypertensive encephalopathy
- Consider IV antihypertensives for hypertensive emergencies
Acute Kidney Injury
- Most cases are mild and self-limiting
- Avoid nephrotoxic medications
- Renal replacement therapy is rarely needed but should be considered for:
- Severe uremia
- Refractory hyperkalemia
- Pulmonary edema unresponsive to diuretics
Congestive Heart Failure/Pulmonary Edema
- Oxygen supplementation as needed
- Diuretics (furosemide)
- Fluid restriction
- Sitting position to improve ventilation
Important Considerations
- Immunosuppression is generally not indicated for typical PSGN unless severe crescentic glomerulonephritis is present 1
- Kidney biopsy is rarely needed and reserved for:
- Diagnostic uncertainty
- Rapidly progressive glomerulonephritis
- Atypical disease progression 3
- Most patients make a full recovery with supportive care alone 3, 4
Follow-up and Monitoring
- Regular monitoring of renal function, urinalysis, and blood pressure
- Long-term follow-up is recommended as a small percentage (approximately 7%) may develop persistent hypertension 2
- Persistent proteinuria, hypertension, or abnormal renal function beyond the acute phase may require extended monitoring 4
- Poor prognostic indicators include:
- Persistent hypertension beyond the acute phase
- Crescent formation on renal biopsy
- Significant renal insufficiency at presentation 5
By following these management principles, most patients with PSGN will recover completely without long-term sequelae, though a small percentage may develop chronic kidney disease requiring ongoing care.