What is the management of post-streptococcal glomerulonephritis (PSGN)?

Management of Post-Streptococcal Glomerulonephritis (PSGN)

The management of post-streptococcal glomerulonephritis primarily involves appropriate antibiotic treatment of the streptococcal infection and supportive care for kidney manifestations, with corticosteroids reserved only for severe crescentic cases. 1

Pathophysiology

• PSGN is an immune complex-mediated disease where streptococcal antigens trigger immune complex deposition in glomerular tissue, causing inflammation and kidney damage 2
• The disease typically occurs 1-3 weeks after streptococcal pharyngitis or impetigo 1
• Activation of the alternate complement pathway leads to glomerular inflammation and subsequent kidney injury 3

Initial Management

Antimicrobial Therapy

• Treat with penicillin (or erythromycin if penicillin-allergic) even in the absence of persistent infection to decrease antigenic load 1
• Systemic antimicrobials should be used during outbreaks of PSGN to help eliminate nephritogenic strains of Streptococcus pyogenes from the community 1

Supportive Care for Nephritic Syndrome

• Manage hypertension with diuretics and antihypertensive medications 1, 2
  • Nifedipine has shown advantages in controlling acute hypertension 4
  • ACE inhibitors (captopril, enalapril) demonstrate better control of blood pressure and echocardiographic changes compared to other antihypertensives 4
• Restrict dietary sodium intake 1
• Monitor for and treat fluid overload with diuretics 1
• Provide dialysis if necessary for severe cases with acute kidney injury 1

Special Considerations

Severe Cases

• For severe crescentic PSGN, corticosteroids may be considered based on anecdotal evidence only 1, 2
• A case report suggests that aggressive treatment with corticosteroids in crescentic PSGN with nephrotic syndrome can result in favorable outcomes 5
• However, combined immunosuppressants for crescentic PSGN have not shown advantages over supportive therapy alone in limited studies 4

Monitoring

• Regular assessment of kidney function, blood pressure, proteinuria, and hematuria 1
• Monitor for complications such as hypertensive emergencies, congestive heart failure, nephrotic syndrome, and severe acute kidney injury 3
• Pay particular attention to adverse effects of diuretics including hyponatremia, hypokalemia, GFR reduction, and volume depletion 1

Prognosis and Follow-up

• Most patients with PSGN have an excellent prognosis, particularly in the epidemic form 4, 6
• Hypertension is common (95%) in the acute phase but typically resolves within 3-5 days with normalization of glomerular filtration rate and plasma volume 7
• Long-term follow-up is recommended as some patients may develop persistent proteinuria, hypertension, or progression to chronic kidney disease 3, 6
• Histological resolution may take up to 9 years in some cases 6
• Persistent hypertension during disease evolution (found in approximately 6.8% of patients) may be a poor prognostic sign 7

Treatment Algorithm

1. Confirm diagnosis through clinical presentation, serologic studies, and kidney biopsy if necessary
2. Administer appropriate antibiotics (penicillin or erythromycin) regardless of active infection status
3. Implement supportive care:
   • Control hypertension with diuretics and antihypertensives
   • Restrict sodium intake
   • Monitor fluid status and kidney function
4. Consider corticosteroids only for severe crescentic disease
5. Provide dialysis if necessary for severe acute kidney injury
6. Establish regular follow-up to monitor for long-term complications