Chapter 30 Glomerulonephritis
PATHOPHYSIOLOGY
Glomerulonephritis is a term used for a collection of disorders that involve the renal glomeruli, which are responsible for filtering body fluids and wastes. Two types of this disease are seen, acute and chronic, with chronic being the progressive form. Acute glomerulonephritis is the most common form of nephritis in children. It is an inflammation of the glomeruli that usually follows a streptococcal upper respiratory tract infection. It is considered an immune-complex disease. The glomerular injury is induced by antigen-antibody complexes trapped in the glomerular filter. The glomeruli become edematous and are infiltrated with polymorphonuclear leukocytes, which occlude the capillary lumen. This condition results in decreased plasma filtration, causing excessive accumulation of water and retention of sodium. The resultant plasma and interstitial fluid volumes lead to circulatory congestion and edema. Hypertension is associated with glomerulonephritis.
INCIDENCE
1. Glomerulonephritis is most common in school-aged children.
2. Ages of peak incidence are from 2 to 6 years.
3. The disorder occurs predominantly in boys in childhood; in adolescence, no male or female predilection is seen.
4. Of children with acute glomerulonephritis, 60% to 80% have a history of a preceding upper respiratory tract infection or otitis media (typically, the child was in good health before the infection).
CLINICAL MANIFESTATIONS
1. Nephritis tends to have an average latency period of approximately 10 days, with onset of symptoms 10 days after the initial infection.
2. Initial signs are puffiness of the face, periorbital edema, anorexia, and dark urine.
3. Edema tends to be more prominent in the face in the morning; then it spreads to the abdomen and the extremities during the day (moderate edema may not be recognized by someone who is unfamiliar with the child).
4. Urinary output is decreased.
5. Urine is cloudy or smoky, or described as having the color of tea or cola.
6. The child is pale, irritable, and lethargic.
7. Younger children may appear ill but seldom express specific complaints.
8. Older children may complain of headaches, abdominal discomfort, vomiting, and dysuria.
COMPLICATIONS
Once acute glomerulonephritis progresses to the chronic stage, the following complications may be seen:
1. Deteriorating renal function (generally reflected by clinical manifestations and laboratory findings)
6. Anemia (manifestation of progressive disease)
7. Hypertensive encephalopathy (characterized by headache, vomiting, irritability, convulsions, and coma)—can result from the chronic hypertension
8. Cardiac failure, possibly a result of an increase in blood volume secondary to retention of sodium and water—associated with pulmonary congestion
LABORATORY AND DIAGNOSTIC TESTS
No diagnostic tests are specifically indicated for the diagnosis of glomerulonephritis. However, the following are commonly performed:
1. Examination of urine—proteinuria (1 to 4), hematuria; presence of casts, red blood cells, and white blood cells; decreased creatinine clearance rates
2. Blood tests—elevated blood urea nitrogen, serum creatinine, and uric acid levels; electrolyte alterations (metabolic acidosis; decreased sodium and calcium; increased potassium, phosphorus, serum albumin, and cholesterol); mild anemia and leukocytosis; elevated antibody titers (antistreptolysin, antihyaluronidase, or antideoxyribonuclease B) and erythrocyte sedimentation rate
3. Renal biopsy—may be indicated; if performed, possible findings are increased number of cells in each glomerulus and subepithelial “humps” containing immunoglobulin and complement
MEDICAL MANAGEMENT
Acute glomerulonephritis has no specific treatment; thus therapy is targeted at the symptoms. Marked hypertension may be treated with diuretics and/or antihypertensives. Appropriate antibiotics are used for acute infections. Some medicinal approaches for treatment of chronic glomerulonephritis have included administration of glucocorticoids and immunosuppressive agents.
NURSING INTERVENTIONS
1. Maintain bed rest and keep child comfortable until diuresis occurs; after diuresis, encourage quiet activity.
2. Closely monitor vital signs (especially blood pressure).
3. When hypertension is present, limit sodium intake and administer ordered medications.
4. Monitor urine for protein and occult blood.
5. Promote adequate nutritional intake: encourage high-carbohydrate meals, serve preferred foods, and try small, frequent feedings.
6. Limit potassium intake if hyperkalemia occurs.
7. Record weight daily and accurately record intake and output.
8. Monitor for complications—significant changes in vital signs, change in appearance or volume of urine, excessive weight gain, visual disturbances, motor disturbances, seizure activity, severe pain, or any behavioral changes.
Discharge Planning and Home Care
1. Provide family with education about child’s illness and treatment plan.
2. Instruct about any medications child will take at home.
3. Instruct parents and child to monitor blood pressure and weight, and to obtain urinalyses for several months; follow-up appointments should be arranged.
4. Instruct parents to contact physician if any change is seen in child’s condition, such as signs of infection, edema, alteration in eating habits, abdominal pain, headaches, change in appearance or amount of urine, or lethargy.
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