What is the management of Post Streptococcal Glomerulonephritis (PSGN)?

Management of Post-Streptococcal Glomerulonephritis

Treat all patients with penicillin (or erythromycin if penicillin-allergic) regardless of whether active infection is present, combined with supportive care focused on managing hypertension and fluid overload through sodium restriction and diuretics. 1

Antibiotic Therapy

• Administer penicillin or erythromycin to all patients even without persistent infection to decrease antigenic load and reduce streptococcal burden 1
• First-generation cephalosporins (like cephalexin) are effective alternatives for non-anaphylactic penicillin allergies or when beta-lactamase producing organisms are suspected 1
• During community outbreaks, use systemic antimicrobials to eliminate nephritogenic strains of Streptococcus pyogenes from the population 1
• Third-generation cephalosporins (like ceftriaxone) should be reserved for severe infections or areas with high resistance prevalence 1

Supportive Care for Nephritic Syndrome

Fluid and Sodium Management

• Restrict sodium intake to <2.0 g/day to control hypertension and fluid retention 1
• Monitor fluid status closely as hypervolemia can lead to congestive heart failure, pulmonary edema, and hypertensive encephalopathy 2

Blood Pressure Control

• Use diuretics as first-line agents for managing hypertension and fluid overload 1, 3
• ACE inhibitors (captopril or enalapril) provide superior blood pressure control and better echocardiographic outcomes compared to other antihypertensives 4
• Nifedipine is effective for acute hypertensive episodes requiring rapid control 4
• Monitor for diuretic-related adverse effects including hyponatremia, hypokalemia, GFR reduction, and volume depletion 1

Metabolic Management

• Treat metabolic acidosis when serum bicarbonate falls below 22 mmol/L 1
• Consider treating dyslipidemia in patients who develop nephrotic syndrome, particularly those with additional cardiovascular risk factors 1

Management of Severe Disease

Crescentic or Rapidly Progressive PSGN

• For patients with crescentic PSGN or rapidly progressive glomerulonephritis, high-dose glucocorticoids and immunosuppressive therapy may be considered, though evidence is limited and anecdotal 1
• For most patients with eGFR <30 ml/min per 1.73 m², supportive care alone is recommended over immunosuppression 1
• One controlled trial showed no advantage of combined immunosuppressants over supportive therapy alone for crescentic disease 4

Renal Replacement Therapy

• Provide dialysis for severe acute kidney injury when conservative management fails 1, 3
• Indications include severe hypervolemia unresponsive to diuretics, life-threatening hyperkalemia, or uremic complications 3

Monitoring and Follow-Up

Short-Term Monitoring

• Regularly assess kidney function, blood pressure, proteinuria, and hematuria throughout the acute phase 1
• Monitor C3 complement levels, which should normalize within 8-12 weeks in uncomplicated cases 1

Long-Term Surveillance

• If C3 levels remain low beyond 12 weeks, perform kidney biopsy to exclude complement C3 glomerulonephritis (C3GN) 1
• Other indications for kidney biopsy include diagnostic uncertainty, atypical presentation, or rapidly progressive disease 1, 3
• Monitor for persistent proteinuria, hypertension, and progression to chronic kidney disease, which may require long-term follow-up 3

Clinical Pitfalls to Avoid

• Do not withhold antibiotics based on absence of active infection—the goal is to reduce antigenic load, not treat active disease 1
• Avoid aggressive immunosuppression in typical cases, as the disease is self-limiting and most patients recover with supportive care alone 3, 2
• Do not dismiss persistently low C3 beyond 12 weeks as this may indicate an alternative diagnosis requiring different management 1
• Be vigilant for acute complications during the first few weeks, including hypertensive emergencies and pulmonary edema from fluid overload 2

Prognosis Considerations

• The majority of children have excellent prognosis with complete recovery 3, 5
• Adults may have slower histological resolution, potentially taking up to 9 years for complete resolution 6
• Crescent formation on biopsy and renal insufficiency at presentation predict worse outcomes 2
• Persistent urinary abnormalities, hypertension, or chronic kidney disease develop in only a small percentage of patients 3, 2