Management of Post-Streptococcal Glomerulonephritis (PSGN)
The management of post-streptococcal glomerulonephritis is primarily supportive care, focusing on treating hypertension, fluid overload, and administering antibiotics to eliminate streptococcal infection, with most patients having excellent outcomes without the need for immunosuppressive therapy. 1, 2
Initial Assessment and Diagnosis
- Confirm diagnosis through clinical presentation (recent streptococcal pharyngitis or impetigo), laboratory findings (hematuria, proteinuria, elevated ASO titers, low C3 complement levels), and kidney biopsy if presentation is atypical 1
- Evaluate for complications including hypertension, fluid overload, acute kidney injury, and rarely, rapidly progressive glomerulonephritis 2, 3
Antimicrobial Therapy
- Administer appropriate antibiotics (penicillin or erythromycin if penicillin-allergic) even if active infection is no longer present, to eliminate residual streptococcal antigens 1
- Systemic antimicrobials should be used during outbreaks of PSGN to help eliminate nephritogenic strains of Streptococcus pyogenes from the community 4, 1
- No advantages of other antimicrobials (cefuroxim, ceftibuten) over standard 10-day penicillin V treatment have been demonstrated 5
Management of Hypertension and Fluid Overload
- Restrict sodium intake to <2.0 g/day to help manage hypertension and fluid retention 4, 1
- Diuretics (primarily furosemide) are first-line therapy for managing fluid overload and hypertension 1, 6
- For persistent or severe hypertension, ACE inhibitors (captopril, enalapril) have shown better control of blood pressure and improved echocardiographic changes compared to other antihypertensive medications 5
- Calcium channel blockers like nifedipine have demonstrated advantages in controlling acute hypertension 5
- Monitor for and treat adverse effects of diuretics including hyponatremia, hypokalemia, and volume depletion 1
Supportive Care
- Dietary modifications including sodium restriction and appropriate protein intake based on the degree of proteinuria and kidney function 4, 1
- Regular monitoring of kidney function, blood pressure, proteinuria, and hematuria 1, 3
- Treat metabolic acidosis if serum bicarbonate is <22 mmol/l 4
- Consider treating dyslipidemia in patients with nephrotic syndrome, particularly those with other cardiovascular risk factors 4
Management of Severe Cases
- For patients with severe acute kidney injury, renal replacement therapy (dialysis) may be necessary 1, 2, 3
- For patients with crescentic PSGN or rapidly progressive glomerulonephritis, high-dose glucocorticoids and immunosuppressive therapy may be considered, though evidence for this approach is limited and anecdotal 4, 1
- For most patients with idiopathic immune complex glomerulonephritis presenting with an eGFR <30 ml/min per 1.73 m², supportive care alone is recommended 4
Prognosis and Follow-up
- Most patients with PSGN have excellent outcomes with complete recovery 2, 3
- Regular follow-up to monitor for persistent proteinuria, hypertension, or progression to chronic kidney disease 1, 3
- Poor prognostic indicators include crescent formation on renal biopsy, persistent hypertension, and significant renal insufficiency at presentation 3