Overview of the Disease
RENAL FUNCTION
Acute glomerulonephritis (AGN) is active
inflammation in the glomeruli. Each kidney is composed of
about 1 million microscopic filtering "screens" known as
glomeruli that selectively remove waste products. The
inflammatory process usually begins with an infection or
injury such as a burn, or trauma then the protective immune
system fights off the infection, scar tissue forms, and the
process is complete.
Acute glomerulonephritis occurs frequently in
children as a result of the delayed hypersensitivity reaction
initiated by infectious agents like streptococci, often
identified as causing tonsillitis or scarlet fever 1-2 weeks
before the disease develops. All post infectious diseases are
presumed to result from immune complex formation and
glomerular deposition, and the clinical presentations may be
indistinguishable. This can occur at any age but primarily
affects early school – age children. It is uncommon in
children younger than 2 years of age.
Acute Glomerulonephritis (AGN) as a classification
includes a number of distinct entities. It may be a primary
event or a manifestation of a systemic disorder, and the
disease can range from minimum to severe. The common
features include oliguria, edema, hypertension and
circulatory congestion, hematuria and proteinuria.
Majority of the patients recover completely; 5-10%
progress to nephritic syndrome and chronic nephritis.
Anatomy and Physiology
The kidneys are a pair of bean-shaped organs
with the inner border of hilum directed towards the vertebral
column. Each kidney is surmounted by a suprarenal (adrenal
gland). A thin capsule of fibrous tissue surrounds each
kidney, forming a smooth covering. Beneath this, the kidney
substance lies which is of a deep purple color and consists
of an outer cortical part and an inner medullary part. The
latter is made up of fifteen to sixteen pyramid-shaped
masses, the pyramids of the kidney. The apices of these are
directed towards the hilum, and open into calyces which
communicate with the pelvis o the kidney.
The minute structure of the kidney is composed of
one to one and a half millions of nephrons – the functional
units of the kidney. The nephron consists of a tuft of blood
vessels, the glomeruli surrounded by the Bowman’s capsule.
To each capsule is attached a long tubule, including a
convoluted tubule terminating in the loop of Henle, and an
ascending loop that ultimately connects with a main
collecting tube opening into the renal pelvis.
When blood passes through the glomerular
capillaries of the nephron, filtration occurs. A protein-free
filtration passes through the tubular segments of the nephron
and the cells absorb those substances which the body wants
and leave behind those that are not wanted. The glomeruli
filter 170 liters of solution a day but the volume of urine
excreted in a day is about 1.5 liters, reabsorbing 99% of the
glomerular filtrate in the tubules. In the lower portion (distal)
of the tubules, concentration of urine takes place and this
requires energy. There is also a flow of substances from
plasma directly across the tubular cells into the lumen of the
tubule. Glucose under normal conditions is completely
reabsorbed along the proximal length of the tubules,
whereas creatinine, urea and some of the salts are filtered
both via the glomeruli and also via the proximal tubules to
join the urine.
The kidney has basically three broad functions,
that of:
1. Excretion – where excess water, useless or harmful
materials are removed or cleared and where certain excess
catabolic products such as urea, uric acid (as urates),
creatinine and various salts such as nitrates, sulfates and
phosphates are eliminated. Dead and dying renal cells,
minute amounts of protein especially mucoproteins and
ingested poisons are expelled. When the renal threshold for
a certain substance is exceeded, the excess is excreted in
the urine. Ex: when blood glucose reached a level of 180 mg
%, any excess above the level is excreted.
2. Homeostasis and metabolism – related to the first
function, useful substances necessary for physiologic
functions are conserved through reabsorption. When these
are not in excess of bodily needs, i.e., glucose, amino acids,
ions such as Na, K, Mg, Ca, P, vitamins, etc. The kidney
also maintains acid-base and electrolyte balance and normal
nutrition.
3. Endocrine – primarily deals with hormones secreted by
the organ like renin, erythropoietin and prostaglandins.
If the kidneys are diseased, the kidneys are not
able to perform their functions well and there are certain
methods which will be helpful in locating the site of
impairment of renal function and which will also add to our
information concerning the normal biochemical function of
the cells of the kidney. Of these the most useful are:
1) Testing the urine for albumin or protein. If the
glomeruli or tubules are damaged, protein leaks
into the urine.
2) Measuring the blood urea concentration. If the
kidneys are not excreting enough urea, the blood
urea rises above the normal value of 25-40 mg %.
3) Determining the urine to plasma ratio as an
index of concentrating and absorbing capacity of
the kidneys.
4) The urinary deposit may be examined for red
blood cells and casts, etc.
DISEASES OF THE KIDNEY
Any damage to the kidney might interfere with one
or all functions of the kidney depending upon the extent of
the damage. With destruction of less than 50% of the
nephrons, the kidneys are sstill able to carry on with the
work load that they are subjected to. With 60% or more,
renal failure sets in manifested by azotemia, anemia,
electrolyte imbalance and acidosis. Nephritis is the term
used to describe a group of non-infective kidney diseases
representing three broad types: acute glomerulo-nephritis,
nephritic syndrome and chronic nephitis.
Cause
It is now generally accepted that Acute
Glomerulonephritis is an immune – complex disease (it is a
reaction that occurs as a by – product of an antecedent
streptococcal infection with certain strains of the group A ß –
haemolytic streptococci. A latent period of 10 to 14 days
occurs between the streptococcal infection of the throat or
skin and the onset of clinical manifestations.
Post infectious etiologies
• The most common cause is post infectious
Streptococcus species.
• Other specific agents include viruses and
parasites, systemic and renal disease, visceral
abscesses, endocarditis, infected grafts or shunts,
and pneumonia.
 • Bacterial causes other than group A streptococci
may be diplococcal, streptococcal, staphylococcal,
or mycobacterial. Cytomegalovirus, rubella, and
mumps are accepted as viral causes only if it can
be documented that a recent group a ß -
haemolytic streptococcal infection did not occur.
• Fungal and parasitic: Attributing
glomerulonephritis to a parasitic or fungal etiology
requires the exclusion of a streptococcal infection

Signs and Symptoms

The onset of AGN appears as after an average

latent period of approximately 10 days. Initial signs of
nephritic reaction include puffiness of the face, especially
around the eyes (periorbital edema); anorexia and the
passage of dark – colored urine.

Overall Appearance
The child is pale, irritable and lethargic, and unwell and
appears unwell but seldom expresses specific complaints.

Edema
The edema is more prominent in the face in the morning but
spreads during the day to involve the extremities and
abdomen.

Oliguria, Dysuria, Azotemia and Hematuria

The disease may be characterized by hematuria
and albuminuria (due to the damage of the renal filtering
mechanism) resulting in a cloudy urine.

The urine is cloudy, smoky brown, or what parents

describe as resembling cola or tea, and it is severely
reduced in volume. A diminished output of urine or oliguria
causes retention of waste products as a result of reduced
glomerular filtration rate.

Hematuria is a universal finding, even if it is

macroscopic. Older children may complain of dysuria or pain
when urinating.

Hypertension
Hypertension occurs as a result of circulatory
congestion because of damaged blood vessels in the kidney.
Upon examination, there is usually a mild to moderate
elevation of blood pressure compared with normal values for
age. Headache may occur secondary to hypertension.

Seizures
Occasionally, a child will have an onset with
severe symptoms such as seizures from hypertensive
encephalopathy, pulmonary and circulatory congestion or
hematuria in the absence of hypertension and edema.

Other Signs and Symptoms

Older children may complain of abdominal
discomfort due to the stretching of the renal capsule. Skin
rashes may also be observed. Other signs include:
Pharyngitis, Impetigo, Respiratory infection, pulmonary
hemorrhage, Heart murmur that may indicate endocarditis,
Weight gain, Anorexia, Back pain and Skin pallor.