Glomerulonephritis in children is a syndrome of heterogeneous diseases affecting the glomeruli of the kidneys, or nephrons, which are the main building block of this organ. Manifested by hematuria, proteinuria, swelling of the face and problems with urination. The disease can occur in acute or chronic form. Consider what is glomerulonephritis, symptoms and treatment in children.
What is glomerulonephritis in children?
The kidneys are a paired organ responsible for removing waste, water and electrolytes (potassium, sodium, calcium) from the body in the urine. Their acute or chronic damage leads to a temporary or permanent deterioration in activity.
The main link of the kidneys responsible for filtration activity (cleaning) are glomeruli (glomeruli of the kidneys). The main component of the glomeruli is their membrane, which is designed to filter the blood and remove accumulated substances andwater into urine. In the case of normal kidney function, the filter membrane retains all the necessary ingredients in the human blood, including protein, so normal protein is not observed in the urine test.
Glomerulonephritis is a group of diseases that are based on damage to the glomerular filtration membrane, which begins to leak protein and red blood cells into the urine. This may be due to viral or bacterial infections. The disease may also have a genetic background. It can occur in an acute, short-term manner, usually associated with infections (eg, after strep throat), or in a chronic manner, in some cases leading to permanent kidney damage.
Types of glomerulonephritis
The following types of this disease are distinguished:
- hematuric - there is hematuria and arterial hypertension;
- nephrotic - hydrothorax appears, pronounced edema;
- hypertensive - high blood pressure;
- combined - combines all the symptoms of the above forms;
- hidden (latent) - with no symptoms.
The latent form of the disease is more dangerous, since its asymptomatic course can last 10-15 years. Its detection is possible either by accident in the analysis of urine, or with the development of complications. Has a favorable prognosis with timely treatment. Hematuric glomerulonephritis in children, as well as the nephrotic type of the disease, have a relatively unfavorable outcome. With an acute form and early diagnosis and adequate therapy, completerecovery. If no medical measures are taken within six months or the wrong treatment regimen is applied, the process becomes chronic. Standards for the treatment of acute glomerulonephritis in children differ from the methods of therapy used in the chronic form of the disease. In the latter case, therapy will be longer, more complex and expensive, and the prognosis will be less comforting.
What is acute glomerulonephritis and what are its causes?
Children are more likely to suffer from acute glomerulonephritis than adults. Pathology occurs more often in boys than in girls. The peak incidence occurs at school age (7-10 years), children under 3 years of age rarely get sick. Acute glomerulonephritis accounts for about 10-15% of all types of glomerulonephritis and occurs in 2-5 cases per 100,000 children per year.
The most common acute glomerulonephritis is preceded by an upper respiratory or skin infection. The main role in the formation of the acute form of the disease is played by immune complexes (the body's response to infection), which damage the filtration membrane of the glomeruli, which leads to the appearance of protein and red blood cells in the urine.
How acute glomerulonephritis manifests itself
Most often, the disease begins with the appearance of edema located on the face (swollen eyes after sleep) or around the ankles on the legs, as well as hematuria. Urine may be red or dark brown. Children usually do not have a temperature during this period. These changes appear 5-21 days after inflammation of the throat and upper respiratory tract.or 3-4 weeks after dermatitis. Edema occurs in almost all patients. It can persist up to two weeks after the onset of the disease and is associated with water and sodium retention in the body. The child complains of abdominal pain, vomiting, headache, apathy appears, appetite worsens. These changes are often accompanied by hypertension.
In rare cases, with significantly elevated blood pressure, a so-called hypertensive crisis with convulsions can occur. In some cases, there is a significant decrease in the amount of urine, up to the occurrence of acute renal failure, including anuria. If the color of the urine changes, swelling of the face or ankle appears, consult a doctor immediately for the correct diagnosis and treatment of glomerulonephritis in children.
How does a doctor make a diagnosis?
Lab tests:
The main laboratory test is a urinalysis, which should always be performed when acute glomerulonephritis is suspected. Characteristic deviations in this study:
- microscopic bleeding (that is, the presence of red blood cells in the urine in an amount not visible to the naked eye, but detectable by microscopic examination), which is a constant symptom of the disease;
- proteinuria - the amount of protein lost in the urine during the day, usually does not exceed 3 g;
- presence of white blood cells (rare).
Blood test shows:
- decrease in complement component C3 and hemolyticcomplement activity (CH50);
- increase in ASO titer (antistreptolysin O) above 200 IU;
- moderately severe anemia;
- in half of the cases, an increase in the concentration of immunoglobulin IgG.
When observing the above deviations in studies in children with glomerulonephritis, treatment and clinical examination are carried out under the supervision of a nephrologist.
If you suspect acute glomerulonephritis in a hospital, you should measure blood pressure, and then repeat the observation of its jumps 3-4 times a day. Ultrasound scanning of the kidneys usually does not show characteristic changes. In the vast majority of cases, there is no need for a kidney biopsy. A biopsy is performed only with prolonged excretion of a small amount of urine from the body to differentiate from acute renal failure or rapidly progressive glomerulonephritis.
Treatment of acute glomerulonephritis in children
Treatment of the acute form of the disease is symptomatic and is usually carried out in a hospital. It is necessary to provide the patient with peace and rest. Treatment of glomerulonephritis in children also consists in getting rid of arterial hypertension and diuretic hypertension.
Antibiotic therapy is indicated for the development of acute glomerulonephritis with pharyngitis, tonsillitis, skin lesions, especially with positive results of cultures from the throat or with high titers of antistreptococcal antibodies in the blood.
Treatment of acute post-streptococcal glomerulonephritis in children is carried out with antibiotics from the grouppenicillins, cephalosporins for 10 days.
If proteinuria is high, the child is given a 20% solution of human albumin. When a child does not urinate for a long time and the swelling increases, doctors may consider kidney replacement therapy (dialysis). After discharge from the hospital, a periodic urine test should be performed (once every two weeks). In case of long-term observation of changes in the urine (hematuria, proteinuria), it is necessary to contact a pediatric nephrologist.
Is it possible to fully recover?
Acute glomerulonephritis is a serious disease, but with a good prognosis. Most symptoms disappear completely within a few weeks or months. With proper treatment of acute glomerulonephritis in children, relapses of the disease are rare. However, you should be aware of periodic urine tests (once a quarter) and blood pressure measurements. For at least one year after acute glomerulonephritis, the child should be under the supervision of a nephrologist.
What is chronic glomerulonephritis and what are its causes
The cause of chronic forms of glomerulonephritis are violations of the child's immune mechanism. As a result of the body's reaction to infection, antibodies are formed against glomerular antigens and immunological deposits that accumulate in the vessels or kidneys and damage the membrane. Chronic glomerulonephritis may be primary (only the kidneys) or secondary to lesions elsewhere (eg, viral hepatitis, systemic disease, cancer). In childhoodchronic glomerulonephritis predominates. In children, the symptoms, causes, treatment of the disease are very diverse and depend on the type of glomerular inflammation. Most patients have proteinuria, hematuria, and edema. In some cases, a recurrence of the disease occurs, for example, caused by an upper respiratory tract infection.
The diagnosis of certain types of glomerulonephritis depends only on a kidney biopsy. This is important because different types of the disease can present with similar symptoms, and the specific treatment for the disease depends on its form.
How does chronic glomerulonephritis manifest itself?
Glomerulonephritis is most often manifested by proteinuria and edema, sometimes with hematuria. The onset of the disease may be insidious without any visible clinical symptoms. The child may be lethargic, complain of lack of appetite. Gradually, swelling may appear on the face near the eyes, especially after sleep, on the legs around the ankles, or swelling visible throughout the child's body. The child quickly gains weight, despite poor appetite. Swelling can be detected by pressing on the child's foot around the ankle. When it is swollen, a "dimple" remains after pressure - small with slight swelling and deeper with great swelling.
In children from 1 to 12 years old, the most common type of illness is the so-called idiopathic nephrotic syndrome. It occurs with a frequency of 2-7 cases per 100,000 children per year. In young children, boys are 2-3 times more likely to develop the disease than girls. Most cases are registered before the age of six. A typical feature of idiopathic nephrotic syndrome is its recurrence. If edema occurs (for example, difficulty in putting on shoes, rapid weight gain), it is urgent to see a doctor for a correct diagnosis, and if glomerulonephritis is confirmed in children, the doctor should prescribe treatment according to the type of disease.
Diagnosis
Basic research - urinalysis. If protein is found in the urine, it is necessary to repeat the analysis again after 1-2 days to assess whether protein losses are increasing. As directed by your doctor, a daily urine collection may be required. This is done by collecting each portion of urine 24 hours a day and pouring it into a container to estimate how much protein the baby is losing. If protein excretion is found to be greater than 50 mg/kg/day, nephrotic proteinuria is observed. Blood tests should evaluate the concentration of albumin, total protein, urea, creatinine, calcium, cholesterol. The blood coagulation system should also be evaluated as the onset of nephrotic syndrome predisposing to thrombosis, which can lead to embolism in the blood vessels.
Basic examination - kidney biopsy
A kidney biopsy involves removing a small portion of the affected kidney. In older children (from 6 to 7 years old), the procedure is performed under local anesthesia under ultrasound guidance. The child should pass it on an empty stomach. Before the procedure, it is necessary to conduct a study on blood clotting. Biopsy can only be donechildren vaccinated with hepatitis B (after antibody titration). If the antibody titer is below protective, parents should vaccinate the child against hepatitis B. In the case of young children (under 6 years), anesthesia should be performed to excise a piece of tissue from the kidney.
Before the biopsy test, the child's parents are asked to agree to the proposed examination. Like any invasive procedure, a small percentage of kidney biopsies are burdened with complications, mainly bleeding and hematoma formation around the kidney. After the biopsy, the child should lie on their back for the next 12 hours to reduce the risk of bruising.
In most children, the first manifestation of nephrotic syndrome does not require a kidney biopsy. This means that under the microscope, the structure of the kidney can look correct without any abnormalities.
Also, there are indications for a biopsy when:
- atypical age of the child at the time of illness (less than 1 year or older than 12 years);
- treatment-resistant nephrotic syndrome;
Need to check for parenchymal changes after prolonged treatment and when kidney function deteriorates
Treatment of chronic glomerulonephritis in children
Treatment usually starts in a hospital. In the case of nephrotic syndrome with large edema, glucocorticosteroids (methylprednisolone) are administered intravenously. Oral prednisone is used if the protein loss is small and not accompanied by severe edema.
WideThe accepted standard of care for first-line nephrotic syndrome is a 6-month course of tapering glucocorticoid therapy. These regimens are modified in case of steroid dependence or resistance. As in cases of relapse, steroid dependence, and resistance in children with glomerulonephritis, the treatment is changed to other drugs such as Cyclophosphamide - up to 3 months, Chlorambucil - administered for up to 3 months, Cyclosporine-A is used for years or mycophenolate mofetil - at least one year.
In addition to the main treatment (glucocorticosteroids), symptomatic treatment is carried out to eliminate the disorders resulting from severe proteinuria. In case of significant loss of protein with a decrease in the concentration of albumin in the blood, intravenous infusions of a 20% solution of albumin are administered with diuretic therapy (furosemide). Diuretic treatment is given in edematous patients with blood calcium leveling, cholesterol lowering (statins), anticoagulant prophylaxis, and treatment of hypertension if present. With a reduced amount of calcium, calcium and vitamin D3 are introduced. After the disappearance of the symptoms of proteinuria, further treatment can be carried out at home.
Clinical guidelines for the treatment of glomerulonephritis in children:
Reducing the dose of a medication or stopping it completely (without prior approval from a doctor) can be extremely harmful. This can lead to relapse, rehospitalization, and intravenous treatment. This applies mainly to prednisolone,cyclosporine A or mycophenolate mofetil
The main rule for the treatment of children with glomerulonephritis in need of long-term therapy is absolute adherence to the doctor's recommendations
Children should receive specialized nephrology care with periodic monitoring in an outpatient nephrology department. During the treatment of glomerulonephritis in children at home, a periodic urinalysis (general examination) is required. If you develop new swelling, check your urine immediately, evaluate for proteinuria, and contact your doctor or pediatric treatment center. It should be remembered that even a banal infection can provoke a recurrence of nephrotic syndrome (including untreated teeth with inflammation), that is, the reappearance of edema and a decrease in the amount of urine. Then you need to limit the supply of fluid to prevent swelling.
Children should avoid all kinds of infections during treatment with high doses of glucocorticoids and immunosuppressive therapy. In the case of vaccinations, do not forget to use preparations containing live microorganisms. The use of high doses of glucocorticoids and immunosuppressants may reduce the effectiveness of the vaccine, and the vaccination itself may cause relapse. The introduction of a basic vaccination schedule is difficult and each time requires a consultation with a nephrologist.
Most of the complications that occur during nephrotic syndrome are associated with long-term glucocorticoid treatment (short stature, obesity, diabetes, cataracts, changes in bone density) or are the result of a significant loss of protein in the urine (hypercoagulability,hypocalcemia, hypercholesterolemia).
Remissions and relapses
In 90% of children, remission of the disease (urine without protein) is observed with primary nephrotic syndrome. 20% of these children have no relapses, 40% have rare recurrences, and 30% have frequent relapses of the disease (steroid dependence). 10% of children are diagnosed with steroid resistance. The prognosis for the course of nephrotic syndrome depends mainly on the response to treatment. Resistance to standard treatment and dosage of drugs in children with glomerulonephritis is a risk factor for the development of renal failure. In severe cases, it is important to expect that nephrotic syndrome will accompany the patient throughout life. Some children (depending on the type of disease) may develop chronic kidney disease and up to 25% will develop end-stage kidney failure requiring dialysis or a kidney transplant.
Glomerulonephritis is a genetically determined disease
Glomerulonephritis can also be a congenital disease. Sometimes it is severe and appears immediately after birth. Children are usually born prematurely, with a large belly and muscle weakness. As a result of very large losses of protein in the urine, increased edema develops and the risk of thrombotic complications and infections increases. If protein loss cannot be controlled, both kidneys must be removed and treatment initiated with dialysis (usually peritoneal dialysis). After reaching a weight of 7-8 kg, a kidney transplant can be performed. In somecases of genetically determined nephrotic syndromes, the course is not so dramatic. Symptoms can appear at different ages and are similar to those found in other types of glomerulonephritis, i.e. edema, proteinuria, etc. A common feature of genetic nephrotic syndrome is resistance to the applied causative treatment.
Now you know how the symptoms and treatment of glomerulonephritis in children proceed, and what the consequences of improper therapy for the patient may be.
