Management of Post-Streptococcal Glomerulonephritis (PSGN)
The management of post-streptococcal glomerulonephritis primarily consists of supportive care, including diuretics and antihypertensive therapy, with antibiotic therapy to eliminate remaining streptococcal organisms. 1, 2 Most patients recover completely with this approach, and immunosuppressive therapy is rarely required except in severe cases with crescentic involvement.
Diagnosis and Initial Assessment
- Confirm diagnosis through:
- Clinical presentation (acute nephritic syndrome)
- Evidence of recent streptococcal infection (elevated ASO titers)
- Low serum complement levels
- Urinalysis showing hematuria and proteinuria
- Kidney biopsy (if diagnosis uncertain or atypical presentation)
Treatment Algorithm
1. Antibiotic Therapy
- Penicillin (or erythromycin if penicillin-allergic) for 10 days to eliminate remaining streptococcal organisms 1
- This prevents spread but does not alter the course of established PSGN
2. Supportive Care (Primary Treatment)
A. Hypertension Management
- ACE inhibitors or ARBs at maximally tolerated doses 1
- Target systolic BP <120 mmHg in adults
- Target 24-hour mean arterial pressure ≤50th percentile for age, sex, and height in children
- For severe hypertension, additional agents may be required
B. Edema Management
- Dietary sodium restriction (<2.0 g/day) 1
- Diuretics (loop diuretics like furosemide) as first-line therapy 1, 3
- If diuretic response is insufficient, add mechanistically different diuretics with careful monitoring for adverse effects
C. Metabolic Acidosis Management
- Treat if serum bicarbonate is <22 mmol/l 4
3. Special Circumstances
A. Rapidly Progressive/Crescentic PSGN
- High-dose glucocorticoids and cyclophosphamide 4, 5
- Consider pulse-dose intravenous methylprednisolone followed by oral prednisone
- This aggressive approach has shown favorable outcomes in severe cases 5
B. Nephrotic Syndrome with PSGN
- Consider statin therapy for persistent dyslipidemia, particularly with other cardiovascular risk factors 4
- Monitor for thromboembolic events; full anticoagulation indicated if these occur 4
C. Advanced Kidney Dysfunction
- For most patients with eGFR <30 ml/min/1.73 m², supportive care alone is recommended 4
- Exception: cases with active necrotizing or crescentic GN where immunosuppression may still be beneficial
Monitoring and Follow-up
- Regular monitoring of:
- Blood pressure
- Renal function tests
- Urinalysis for proteinuria and hematuria
- Serum electrolytes
- Long-term follow-up recommended as some patients may develop chronic kidney disease
Prognosis
- Most patients with PSGN make a full recovery 2, 6
- Children have better prognosis than adults
- Poor prognostic factors include:
- Persistent hypertension beyond acute phase 3
- Crescentic glomerulonephritis
- Nephrotic-range proteinuria
- Older age at onset
Prevention
- Early treatment of streptococcal throat and skin infections
- Improved hygiene and sanitation measures
- Enhanced access to clean drinking water
Important Considerations
- Kidney biopsy is seldom required except in cases of diagnostic uncertainty, rapidly progressive disease, or atypical progression 2
- Immunosuppressive therapy is not routinely recommended for typical PSGN but may be warranted in aggressive disease with crescents 5
- Persistent proteinuria, hypertension, or declining kidney function beyond the acute phase requires close monitoring and may indicate a worse prognosis 6, 3