What is the treatment for post-streptococcal glomerulonephritis (PSGN) in children and young adults?

Treatment of Post-Streptococcal Glomerulonephritis (PSGN)

The treatment of PSGN in children and young adults is primarily supportive, focusing on managing the nephritic syndrome with diuretics and antihypertensives, while administering penicillin (or erythromycin if penicillin-allergic) to reduce streptococcal antigenic load, even in the absence of active infection. 1, 2

Antibiotic Therapy

Administer antibiotics regardless of whether active infection is still present:

• Penicillin is the first-line antibiotic to decrease the antigenic load, even when the streptococcal infection has resolved 1, 2, 3
• Erythromycin is the alternative for penicillin-allergic patients 1, 2
• First-generation cephalosporins (e.g., cephalexin) are appropriate for non-anaphylactic penicillin allergies 2, 3
• Third-generation cephalosporins (e.g., ceftriaxone) should be used for severe infections or in areas with high prevalence of resistant organisms 2, 3
• During outbreaks, systemic antimicrobials help eliminate nephritogenic strains of Streptococcus pyogenes from the community 2, 3

Critical caveat: Antibiotics do NOT prevent acute glomerulonephritis itself—they only reduce antigenic burden and prevent spread 1

Supportive Management of Nephritic Syndrome

The cornerstone of treatment is managing the clinical manifestations:

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 based on clinical response 1, 2

Blood Pressure 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
• Add additional antihypertensive medications as needed to achieve target blood pressure 1, 2
• Monitor closely for diuretic-related complications: hyponatremia, hypokalemia, GFR reduction, and volume depletion 2, 3

Renal Replacement Therapy

• Provide dialysis if necessary for severe acute kidney injury with uremia, refractory fluid overload, or life-threatening hyperkalemia 1, 2, 3

Additional Supportive Measures

• Treat metabolic acidosis if serum bicarbonate <22 mmol/L 2, 3
• Consider treating dyslipidemia in patients with nephrotic syndrome, particularly those with other cardiovascular risk factors 2

Immunosuppressive Therapy

Corticosteroids should be reserved ONLY for severe crescentic PSGN with rapidly progressive glomerulonephritis:

• Use corticosteroids only for severe crescentic disease based on anecdotal evidence 1, 2, 3
• The evidence quality for immunosuppression is extremely weak, consisting of uncontrolled observational studies 1
• Do NOT use immunosuppression for typical PSGN as the disease is self-limited with excellent prognosis 1, 2, 3
• One small study showed no advantages of combined immunosuppressants over supportive therapy alone for crescentic post-streptococcal glomerulonephritis 4

Important distinction: Do NOT use corticosteroids for IgA-dominant post-infectious glomerulonephritis, which typically occurs with staphylococcal infections 3

Monitoring and Follow-Up

Establish a systematic monitoring protocol:

• Check C3 complement levels at diagnosis and follow serially—C3 should normalize within 8-12 weeks in uncomplicated cases 2, 3
• If C3 remains low beyond 12 weeks, perform kidney biopsy to exclude complement C3 glomerulonephritis (C3GN) 2, 3
• Monitor kidney function (serum creatinine, eGFR), blood pressure, proteinuria (albumin-creatinine ratio or protein-creatinine ratio), and hematuria regularly throughout the disease course 2, 3
• Assess for complications including hypertensive emergencies, congestive cardiac failure, nephrotic syndrome, and severe acute kidney injury 5

Clinical Pitfalls to Avoid

Common errors in PSGN management:

• Do not withhold antibiotics even when active infection is no longer evident—the goal is to reduce antigenic load, not treat active infection 1, 2, 3
• Do not routinely use immunosuppression—the evidence is anecdotal at best and most cases resolve spontaneously 1, 4
• Do not assume all glomerulonephritis after streptococcal infection is PSGN—if C3 remains low beyond 12 weeks, alternative diagnoses like C3 glomerulonephritis must be considered 2, 3
• Do not overlook diuretic-related complications—aggressive diuresis can cause hyponatremia, hypokalemia, and volume depletion 2, 3

Prognosis and Long-Term Considerations

Most patients make a full recovery:

• The majority of children with epidemic APSGN have excellent prognosis 4, 6
• However, persistent proteinuria, hypertension, and progression to chronic kidney disease may occur and require long-term monitoring 5, 6
• Sporadic cases may have poorer long-term outcomes compared to epidemic forms 4