How is acute glomerulonephritis in children treated?

The main directions in the treatment of acute glomerulonephritis in children are the following:

• Physical activity regime.
• Diet therapy.
• Symptomatic therapy:
  • About antibacterial therapy;
  • O diuretics;
  • About antihypertensive drugs.
• Pathogenetic therapy.
• Impact on microthrombotic processes:
  • anticoagulant drugs;
  • antiplatelet drugs.
• Effect on immune inflammation:
  • glucocorticoid drugs;
  • cytostatic drugs.

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Physical activity regime

Bed rest is prescribed for 7-10 days only in conditions associated with the risk of complications: heart failure, angiospastic encephalopathy, acute renal failure. Long-term strict bed rest is not indicated, especially in nephrotic syndrome, as it increases the risk of thromboembolism. Expansion of the regime is allowed after normalization of blood pressure, reduction of edema syndrome and reduction of macrohematuria.

Diet for acute glomerulonephritis in children

The prescribed diet is renal diet No. 7: low-protein, low-sodium, normal-calorie.

Protein is limited (to 1-1.2 g/kg by limiting animal proteins) in patients with impaired renal function with increased urea and creatinine concentrations. In patients with NS, protein is prescribed according to the age norm. Protein is limited for 2-4 weeks until urea and creatinine levels are normalized. In salt-free diet No. 7, food is prepared without salt. The patient receives about 400 mg of sodium chloride in the products included in the diet. When hypertension is normalized and edema disappears, the amount of sodium chloride is increased by 1 g per week, gradually bringing it to the norm.

Diet No. 7 has a high energy value - not less than 2800 kcal/day.

The amount of fluid administered is regulated based on the previous day's diuresis, taking into account extrarenal losses (vomiting, loose stools) and perspiration (500 ml for school-age children). There is no need for special fluid restriction, since there is no thirst on a salt-free diet.

To correct hypokalemia, foods containing potassium are prescribed: raisins, dried apricots, prunes, baked potatoes.

Table No. 7 is prescribed for a long time in acute glomerulonephritis - for the entire period of active manifestations with a gradual and slow expansion of the diet.

In acute glomerulonephritis with isolated hematuria and preserved renal function, dietary restrictions are not applied. Table No. 5 is prescribed.

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Symptomatic treatment of acute glomerulonephritis in children

Antibacterial therapy

Antibacterial therapy is administered to patients from the first days of the disease if a previous streptococcal infection is indicated. Preference is given to antibiotics of the penicillin series (benzylpenicillin, augmentin, amoxiclav), less often macrolides or cephalosporins are prescribed. The duration of treatment is 2-4 weeks (amoxicillin orally 30 mg/(kg x day) in 2-3 doses, amoxiclav orally 20-40 mg/(kg x day) in three doses).

Antiviral therapy is indicated if its etiologic role is proven. Thus, in case of association with the hepatitis B virus, the administration of acyclovir or valacyclovir (Valtrex) is indicated.

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Treatment of edema syndrome

Furosemide (lasix) is a loop diuretic that blocks potassium-sodium transport at the level of the distal tubule. It is prescribed orally or parenterally from 1-2 mg/kg to 3-5 mg/(kg x day). With parenteral administration, the effect occurs in 3-5 minutes, with oral administration - in 30-60 minutes. The duration of action with intramuscular and intravenous administration is 5-6 hours, with oral administration - up to 8 hours. The course is from 1-2 to 10-14 days.

Hydrochlorothiazide - 1 mg/(kg x day) (usually 25-50 mg/day, starting with minimal doses). Breaks between doses - 3-4 days.

Spironolactone (veroshpiron) is a sodium-sparing diuretic, aldosterone antagonist. Prescribed at a dose of 1-3 mg/kg per day in 2-3 doses. Diuretic effect - after 2-3 days.

Osmotic diuretics (polyglucin, rheopolyglucin, albumin) are prescribed to patients with refractory edema with nephrotic syndrome, with severe hypoalbuminemia. As a rule, combination therapy is used: 10-20% albumin solution at a dose of 0.5-1 g / kg per dose, which is administered over 30-60 minutes, followed by furosemide at a dose of 1-2 mg / kg or higher for 60 minutes in a 10% glucose solution4. Instead of albumin, a solution of polyglucin or rheopolyglucin can be administered at a rate of 5-10 ml / kg.

Osmotic diuretics are contraindicated in patients with acute nephritic syndrome, as they have severe hypervolemia and possible complications in the form of acute left ventricular failure and eclampsia.

Treatment of arterial hypertension

AG in ANS is associated with sodium and water retention, with hypervolemia, so in many cases, BP reduction is achieved by a salt-free diet, bed rest, and the administration of furosemide. The dose of furosemide can reach 10 mg/kg per day in hypertensive encephalopathy.

In chronic glomerulonephritis and, less commonly, in acute glomerulonephritis in children, antihypertensive drugs are used.

Calcium channel blockers (nifedipine sublingually 0.25-0.5 mg/kg/day) in 2-3 doses until blood pressure is normalized, amlodipine orally 2.5-5 mg once a day until blood pressure is normalized).

Angiotensin-converting enzyme inhibitors (ACE inhibitors): enalapril orally 5-10 mg/day in 2 doses, until blood pressure is normalized, captopril orally 0.5-1 mg/kg/day in 3 doses, until blood pressure is normalized. The course is 7-10 days or more.

The simultaneous use of these drugs is undesirable, as it may reduce the contractility of the myocardium.

Pathogenetic treatment of acute glomerulonephritis in children

Impact on microthrombotic processes

Sodium heparin has a multifactorial effect:

• suppresses intravascular processes, including intraglomerular coagulation;
• has a diuretic and natriuretic effect (suppresses the production of aldosterone);
• has a hypotensive effect (reduces the production of the vasoconstrictor endothelin by mesangial cells);
• has an antiproteinuric effect (restores the negative charge on the protein membrane).

Sodium heparin is administered subcutaneously at a dose of 150-250 IU/kg (day) in 3-4 doses. The course is 6-8 weeks. Sodium heparin is discontinued gradually by reducing the dose by 500-1000 IU per day.

Dipyridamole (curantil):

• has antiplatelet and antithrombotic effects. The mechanism of action of curantil is associated with an increase in the content of cAMP in platelets, which prevents their adhesion and aggregation;
• stimulates the production of prostacyclin (a powerful antiplatelet agent and vasodilator);
• reduces proteinuria and hematuria, has an antioxidant effect.

Curantil is prescribed in a dose of 3-5 mg/kg/day) for a long time - for 4-8 weeks. It is prescribed as monotherapy and in combination with sodium heparin, glucocorticoids.

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Impact on immune inflammation processes - immunosuppressive therapy

Glucocorticoids (GC) - non-selective immunosuppressants (prednisolone, methylprednisolone):

• have an anti-inflammatory and immunosuppressive effect, reducing the flow of inflammatory (neutrophils) and immune (macrophages) cells into the glomeruli, and thereby inhibit the development of inflammation;
• suppress the activation of T-lymphocytes (as a result of a decrease in the production of IL-2);
• reduce the formation, proliferation and functional activity of various subpopulations of T-lymphocytes.

Depending on the response to hormonal therapy, hormone-sensitive, hormone-resistant and hormone-dependent variants of glomerulonephritis are distinguished.

Prednisolone is prescribed according to the schemes depending on the clinical and morphological variant of glomerulonephritis. In acute glomerulonephritis in children with NS, prednisolone is prescribed orally at the rate of 2 mg/kg x day (no more than 60 mg) continuously for 4-6 weeks, in the absence of remission - up to 6-8 weeks. Then they switch to an alternating course (every other day) at a dose of 1.5 mg/kg x day) or 2/3 of the therapeutic dose in one dose in the morning for 6-8 weeks, followed by a slow decrease of 5 mg per week.

In steroid-sensitive NS, subsequent relapse is stopped with prednisolone at a dose of 2 mg/kg (day) until three normal results of daily urine analysis are obtained, followed by an alternating course for 6-8 weeks.

In frequently recurring and hormone-dependent NS, therapy with prednisolone is started in a standard dose or pulse therapy with methylprednisolone in a dose of 30 mg/kg/day) intravenously three times with an interval of one day for 1-2 weeks, followed by a transition to prednisolone daily, and then to an alternating course. In frequently recurring NS, after the 3-4th relapse, cytostatic therapy may be prescribed.

Cytostatic drugs are used for chronic glomerulonephritis: mixed form and nephrotic form with frequent relapses or hormone-dependent variant.

• Chlorambucil (leukeran) is prescribed at a dose of 0.2 mg/kg/day for two months.
• Cyclophosphamide: 10-20 mg/kg per injection as pulse therapy once every three months or 2 mg/kg x day for 8-12 weeks.
• Cyclosporine: 5-6 mg/kg/day) for 12 months.
• Mycophenolate mofetil: 800 mg/m2 for 6-12 months.

Cytostatic drugs are prescribed in combination with prednisolone. The choice of therapy, the combination of drugs and its duration depend on the clinical, morphological variant and the characteristics of the course.

Depending on the clinical variant and the acute and morphological variant of chronic glomerulonephritis, appropriate treatment regimens are selected.

Here are possible treatment regimens. In acute glomerulonephritis with nephritic syndrome, antibacterial therapy is indicated for 14 days, diuretics, hypotensive agents, as well as curantil and sodium heparin.

In acute glomerulonephritis in children with nephrotic syndrome, the administration of diuretic drugs (furosemide in combination with osmotic diuretics) and prednisolone according to the standard regimen is indicated.

For acute urinary tract infection with isolated urinary syndrome: antibiotics as indicated, curantil and, in some cases, sodium heparin.

In acute glomerulonephritis in children with hypertension and hematuria: diuretic, antihypertensive drugs, prednisolone according to the standard regimen and, if there is no effect, the addition of cytostatics after a kidney biopsy.

In case of CGN (nephrotic form), pathogenetic therapy includes prednisolone, diuretic drugs, curantil, sodium heparin. However, in case of frequently recurring course or hormone resistance, cytostatic drugs should be used. The scheme and duration of their use depends on the morphological variant of glomerulonephritis.

In case of CGN (mixed form), during exacerbation and the presence of edema, diuretics and antihypertensive drugs are prescribed; prednisolone is prescribed as an immunosuppressive therapy in the form of pulse therapy with the addition of cyclosporine.

Treatment of complications of acute glomerulonephritis in children

Hypertensive encephalopathy:

• intravenous administration of furosemide in large doses - up to 10 mg/kg/day);
• intravenous administration of sodium nitroprusside 0.5-10 mcg/(kg x min) or nifedipine sublingually 0.25-0.5 mg/kg every 4-6 hours;
• for convulsive syndrome: 1% solution of diazepam (seduxen) intravenously or intramuscularly.

Acute renal failure:

• furosemide up to 10 mg/kg/day);
• infusion therapy with 20-30% glucose solution in small volumes of 300-400 ml/day;
• in case of hyperkalemia - intravenous administration of calcium gluconate at a dose of 10-30 ml/day;
• administration of sodium bicarbonate in a dose of 0.12-0.15 g of dry matter orally or in enemas.

If azotemia increases above 20-24 mmol/l, potassium increases above 7 mmol/l, pH decreases below 7.25 and anuria lasts for 24 hours, hemodialysis is indicated.

Pulmonary edema:

• furosemide intravenously up to 5-10 mg/kg;
• 2.4% solution of euphyllin intravenously 5-10 ml;
• Corglycon intravenously 0.1 ml per year of life.

Forecast

Acute glomerulonephritis in children has a favorable prognosis. Recovery is observed in 85-90% of cases. Fatal outcome is rare (less than 1%).

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Further management

Dispensary observation is mandatory for 5 years.