What is the treatment for post-streptococcal glomerulonephritis (PSGN)?

Treatment of Post-Streptococcal Glomerulonephritis

Treat all patients with penicillin (or erythromycin if penicillin-allergic) regardless of whether active infection is present, combined with supportive management of fluid overload and hypertension using sodium restriction and diuretics. 1, 2

Antibiotic Therapy

Administer antibiotics to all patients even without active infection to reduce streptococcal antigenic load, which is critical for limiting immune complex formation and glomerular inflammation. 1, 2

• Penicillin is the first-line antibiotic for post-streptococcal glomerulonephritis 1, 2
• Erythromycin should be used for patients with penicillin allergy 1, 2
• First-generation cephalosporins (e.g., cephalexin) are appropriate alternatives for non-anaphylactic penicillin allergies or when beta-lactamase producing organisms are suspected 1, 2
• Third-generation cephalosporins (e.g., ceftriaxone) should be reserved for severe infections or areas with high prevalence of resistant organisms 1, 2
• During outbreaks, systemic antimicrobials help eliminate nephritogenic strains of Streptococcus pyogenes from the community 1

Supportive Management of Nephritic Syndrome

The cornerstone of treatment is managing the clinical manifestations of acute glomerulonephritis, as the disease is fundamentally self-limiting. 2, 3

Sodium and Fluid Management

• Restrict dietary sodium to <2.0 g/day to control hypertension and fluid retention 1, 2
• Monitor fluid status closely, as hypervolemia can lead to congestive heart failure, pulmonary edema, and hypertensive encephalopathy during the acute phase 3

Blood Pressure Control

• Use diuretics (loop or thiazide) as first-line agents for managing both fluid overload and hypertension 1, 2, 4
• Target blood pressure <130/80 mmHg (or <125/75 mmHg if proteinuria >1 g/day) 2
• ACE inhibitors or angiotensin receptor blockers may be effective for hypertension but carry risks of hyperkalemia and temporarily impairing recovery of renal function 4
• Monitor closely for diuretic-related complications including hyponatremia, hypokalemia, GFR reduction, and volume depletion 1, 2

Additional Supportive Measures

• Treat metabolic acidosis if serum bicarbonate <22 mmol/L 1, 2
• Provide dialysis if necessary for severe acute kidney injury with fluid overload unresponsive to diuretics 1
• Consider treating dyslipidemia in patients with nephrotic syndrome, particularly those with other cardiovascular risk factors 1

Immunosuppressive Therapy

Corticosteroids should be considered ONLY for severe crescentic glomerulonephritis with rapidly progressive renal failure, based on anecdotal evidence with weak quality. 1, 2

• Do NOT use corticosteroids routinely for typical post-streptococcal glomerulonephritis, as the disease is self-limiting and most patients recover with supportive care alone 1, 2, 5
• High-dose glucocorticoids and immunosuppressive therapy may be considered for crescentic PSGN, though evidence is limited 1, 2
• One study showed no advantages of combined immunosuppressants over supportive therapy alone for crescentic disease 5

Monitoring and Follow-Up

The most critical period is the first 7-10 days when hypertension, edema, gross hematuria, and impaired renal function are greatest. 4

• Assess C3 complement levels at diagnosis and follow serially—C3 should normalize within 8-12 weeks in uncomplicated cases 1, 2
• If C3 remains low beyond 12 weeks, perform kidney biopsy to exclude complement C3 glomerulonephritis (C3GN) 1, 2
• Monitor kidney function, blood pressure, proteinuria, and hematuria regularly throughout the disease course 1, 2
• Kidney biopsy is indicated when diagnosis is uncertain, atypical presentation occurs, or rapidly progressive glomerulonephritis develops 1, 6

Common Pitfalls to Avoid

• Do not withhold antibiotics even if active infection is no longer present—reducing antigenic load is therapeutic 1, 2
• Do not use corticosteroids for typical cases—reserve only for severe crescentic disease with rapidly progressive renal failure 1, 2
• Do not assume chronic kidney disease if proteinuria persists early—most patients make full recovery, though <10% may have persistent microscopic hematuria or proteinuria requiring long-term monitoring 6, 4
• Be vigilant during the first 7-10 days when complications like hypertensive emergencies and congestive heart failure are most likely 3, 4