Treatment of Post-Streptococcal Glomerulonephritis (PSGN) in Pediatric Patients
Post-streptococcal glomerulonephritis in children requires primarily supportive care with antibiotics to eliminate streptococcal infection, diuretics and antihypertensives for symptom management, and close monitoring—immunosuppression is reserved only for the rare cases of severe crescentic disease. 1, 2
Antibiotic Therapy
Administer penicillin (or erythromycin if penicillin-allergic) to all children with PSGN, even without active infection, to decrease antigenic load. 1, 2 This should be given regardless of whether the streptococcal infection is still clinically apparent, as the goal is to reduce the immune complex burden. 1, 3
- First-generation cephalosporins (e.g., cephalexin) are appropriate alternatives for non-anaphylactic penicillin allergies 2
- During outbreaks, systemic antimicrobials help eliminate nephritogenic strains of Streptococcus pyogenes from the community 2
Supportive Management of Nephritic Syndrome
The cornerstone of PSGN treatment is managing the acute nephritic manifestations, which are most severe in the first 7-10 days. 4
Fluid and Sodium Management
- Restrict sodium intake to <2.0 g/day to control hypertension and fluid retention 2
- Monitor fluid status closely, as overhydration is a common complication 5, 6
Hypertension Control
- Loop or thiazide diuretics are the most effective first-line agents for managing both hypertension and edema in PSGN 4, 2
- Nifedipine has demonstrated efficacy for acute hypertensive episodes 7
- ACE inhibitors or ARBs may be used for blood pressure control but carry risks of hyperkalemia and temporarily impaired renal function recovery 4
- The evidence shows ACE inhibitors (captopril, enalapril) provide better blood pressure control and improved echocardiographic changes compared to other antihypertensives 7
Metabolic Complications
- Treat metabolic acidosis if serum bicarbonate is <22 mmol/L 2
- Monitor for and manage hyperkalemia, particularly if using ACE inhibitors or ARBs 4
- Address hyperuricemia if present, as severe cases may require rasburicase 6
Dialysis Indications
Provide dialysis for severe acute kidney injury with:
- Refractory fluid overload 1, 2
- Severe electrolyte abnormalities unresponsive to medical management 2
- Uremic complications 1
Immunosuppression: A Rare Exception
Corticosteroids should be considered ONLY for severe crescentic PSGN with rapidly progressive glomerulonephritis. 1, 2, 3 This recommendation is based on anecdotal evidence only, as controlled trials have shown no advantage of combined immunosuppressants over supportive therapy alone in crescentic post-streptococcal glomerulonephritis. 7
- High-dose glucocorticoids may be used in crescentic disease, though evidence is limited 2
- For most patients, even those with eGFR <30 mL/min/1.73 m², supportive care alone is recommended 2
- The vast majority of children recover with supportive measures only 4, 5
Monitoring Protocol
Monitor the following parameters closely, especially during the first 7-10 days:
- Kidney function (serum creatinine, eGFR) 2, 4
- Blood pressure 2, 4
- Proteinuria (albumin-creatinine or protein-creatinine ratio) 2
- Hematuria 2
- C3 complement levels—if C3 remains low beyond 12 weeks, perform kidney biopsy to exclude C3 glomerulonephritis 2
- Adverse effects of diuretics including hyponatremia, hypokalemia, GFR reduction, and volume depletion 2
Kidney Biopsy Indications
Kidney biopsy is rarely needed but should be performed when: 2
- Diagnosis is uncertain
- Atypical presentation
- Persistently low C3 beyond 12 weeks
- Rapidly progressive glomerulonephritis with consideration for immunosuppression 2, 5
Prognosis
The prognosis for pediatric PSGN is excellent, even in cases with severe initial renal impairment. 4, 6 Most children make a full recovery, though persistent microscopic hematuria and proteinuria may occur in less than 10% of patients. 4 Long-term monitoring is warranted for those with persistent abnormalities, as progression to chronic kidney disease, while rare, can occur. 5, 8