What is the treatment approach for post-streptococcal glomerulonephritis (PSGN) in pediatric patients?

Treatment of Post-Streptococcal Glomerulonephritis in Pediatric Patients

Treatment of post-streptococcal glomerulonephritis (PSGN) in children is primarily supportive, focusing on managing hypertension and fluid overload with diuretics and antihypertensives, while antibiotics (penicillin or erythromycin) should be administered even without active infection to reduce antigenic load. 1, 2

Antibiotic Therapy

• Administer penicillin (or erythromycin if penicillin-allergic) to all children with PSGN, even in the absence of persistent infection, to decrease the streptococcal antigenic load. 1, 2, 3
• This should be given regardless of whether the initial pharyngitis or impetigo has resolved, as the goal is to eliminate residual streptococcal antigens. 1, 2
• First-generation cephalosporins (e.g., cephalexin) are appropriate alternatives for non-anaphylactic penicillin allergies. 2, 3
• During community outbreaks, systemic antimicrobials should be used to eliminate nephritogenic strains of Streptococcus pyogenes. 2, 3

Management of Nephritic Syndrome

Fluid and Sodium Management

• Restrict dietary sodium to <2.0 g/day to control hypertension and fluid retention. 2, 3
• Monitor fluid status closely and adjust intake based on clinical assessment of volume overload. 2, 3

Hypertension Control

• Use diuretics as first-line agents for managing both fluid overload and hypertension. 1, 2, 3
• Target blood pressure <130/80 mmHg (or <125/75 mmHg if proteinuria >1 g/day). 3
• ACE inhibitors (captopril or enalapril) provide superior blood pressure control compared to other antihypertensive drugs in children with PSGN. 4
• Nifedipine can be used for acute hypertensive episodes requiring rapid control. 4
• Monitor closely for diuretic-related complications including hyponatremia, hypokalemia, decreased GFR, and volume depletion. 2, 3

Renal Replacement Therapy

• Provide dialysis when necessary for severe acute kidney injury, severe fluid overload unresponsive to diuretics, or life-threatening electrolyte abnormalities. 1, 2, 3

Immunosuppressive Therapy

Corticosteroids should NOT be used routinely in PSGN. 1, 3 The evidence is clear on this point:

• Consider corticosteroids ONLY for severe crescentic PSGN with rapidly progressive renal failure, though this recommendation is based solely on anecdotal evidence. 1, 2, 3
• A randomized controlled trial comparing quintuple immunosuppressive therapy (prednisone, azathioprine, cyclophosphamide, dipyridamole, and heparin/warfarin) versus supportive care alone in children with crescentic PSGN showed no advantage of immunosuppression—all surviving patients maintained normal kidney function regardless of treatment group. 5
• This is a critical pitfall to avoid: the temptation to use immunosuppression in severe cases must be weighed against the lack of evidence for benefit and the self-limited nature of the disease. 5

Monitoring and Follow-Up

• Measure C3 complement levels at diagnosis and follow serially—C3 should normalize within 8-12 weeks in uncomplicated PSGN. 2, 3
• If C3 remains low beyond 12 weeks, perform kidney biopsy to exclude complement C3 glomerulonephritis (C3GN), as this indicates a different disease process. 2, 3
• Monitor kidney function, blood pressure, proteinuria, and hematuria regularly throughout the disease course. 2, 3
• Treat metabolic acidosis if serum bicarbonate <22 mmol/L. 2, 3

Indications for Kidney Biopsy

Kidney biopsy is NOT routinely required but should be performed when: 2, 3

• Diagnosis is uncertain or presentation is atypical
• C3 remains persistently low beyond 12 weeks
• Rapidly progressive glomerulonephritis develops
• Atypical disease progression occurs

Prognosis

• The majority of children with PSGN have an excellent prognosis with complete recovery. 4, 6, 7
• Most patients achieve full recovery with supportive care alone. 6, 7
• A small percentage may develop persistent proteinuria, hypertension, or chronic kidney disease requiring long-term monitoring. 6, 7
• Crescent formation on renal biopsy and renal insufficiency at presentation are predictors of disease severity and potentially poorer outcomes. 7