Management of Post-Streptococcal Glomerulonephritis
Treat post-streptococcal glomerulonephritis with penicillin (or erythromycin if penicillin-allergic) to reduce antigenic load, combined with supportive care including diuretics, antihypertensives, and dialysis when necessary—corticosteroids are reserved only for severe crescentic disease based on anecdotal evidence. 1
Antibiotic Therapy
Even though classic post-streptococcal GN occurs 1-3 weeks after pharyngitis or impetigo, you must still treat with antibiotics even in the absence of persistent infection to decrease the antigenic load 1. This is critical despite the delayed presentation.
Antibiotic regimen:
- First-line: Penicillin V 250 mg four times daily (adults) or 250 mg two-three times daily (children) for 10 days 2
- Alternative: Amoxicillin 500 mg twice daily (adults) or 50 mg/kg once daily (children, max 1000 mg) for 10 days 2
- Penicillin allergy: Erythromycin or first-generation cephalosporin 1
Important caveat: While antibiotics prevent rheumatic fever and reduce spread of streptococcus, there is little evidence they prevent acute glomerulonephritis itself 3. However, they remain indicated to reduce antigenic burden once PSGN has developed.
Supportive Management of Nephritic Syndrome
The cornerstone of treatment is managing the clinical manifestations:
For fluid overload and hypertension:
- Restrict dietary sodium to <2.0 g/day (<90 mmol/day) 4
- Diuretics as first-line agents for edema 1
- Antihypertensives: Target systolic BP <120 mmHg in adults using standardized measurement 4
- ACE inhibitors or ARBs can be used for blood pressure control, but avoid initiating these in acute presentation as they can worsen AKI, especially in minimal change disease-like presentations 4
For severe complications:
- Dialysis for: severe hypervolemia causing pulmonary edema, congestive heart failure, hypertensive encephalopathy, or severe acute kidney injury 1, 5, 6
Role of Immunosuppression
Corticosteroids are NOT routinely indicated for typical post-streptococcal GN 1. The disease is self-limiting in most cases.
Exception - Severe crescentic GN only:
- Consider corticosteroids for rapidly progressive glomerulonephritis with crescents on biopsy
- This recommendation is based on anecdotal evidence only (very weak evidence) 1
- The decision requires kidney biopsy confirmation of crescentic disease 5, 6
When to Perform Kidney Biopsy
Kidney biopsy is not routinely required for typical presentations. Consider biopsy in these specific scenarios 7, 5, 6:
- Diagnostic uncertainty (atypical presentation)
- Rapidly progressive glomerulonephritis with declining kidney function
- Severe acute kidney injury not responding to supportive care
- Persistent proteinuria or declining renal function beyond expected recovery period
- Need to distinguish from IgA-dominant postinfectious GN (which should NOT receive corticosteroids) 1
Critical distinction: IgA-dominant postinfectious GN is increasingly recognized, particularly in elderly patients and diabetics with staphylococcal infections. This variant has worse renal outcomes and must be distinguished from idiopathic IgA nephropathy to avoid inappropriate corticosteroid treatment 1.
Monitoring and Prognosis
Expected clinical course:
- Hematuria, proteinuria, and azotemia may persist for months even with appropriate treatment 1
- Most children have excellent prognosis with complete recovery 5, 6, 8
- Sporadic cases in adults have worse long-term outcomes than epidemic forms in children 9
Monitor for:
- Persistent proteinuria
- Persistent hypertension
- Progressive decline in kidney function suggesting chronic kidney disease 5, 6
Poor prognostic indicators:
- Crescent formation on renal biopsy 6
- Renal insufficiency at presentation 6
- Decreased complement levels, elevated CRP, hypoalbuminemia 6
Common Pitfalls to Avoid
Do not withhold antibiotics thinking the infection has already passed—treat to reduce antigenic load 1
Do not routinely use corticosteroids for typical PSGN—reserve only for severe crescentic disease with biopsy confirmation 1
Do not start ACE inhibitors/ARBs acutely in patients presenting with abrupt nephrotic syndrome—risk of worsening AKI 4
Do not assume all postinfectious GN is streptococcal—consider IgA-dominant variant with staphylococcal infection, especially in elderly/diabetics, which should NOT receive steroids 1