eMedicine Specialties > Emergency Medicine > Genitourinary
Glomerulonephritis, Acute: Follow-up
Updated: Oct 2, 2009
Follow-up
Further Inpatient Care
- A follow-up evaluation by a nephrologist is essential for all patients who do not meet admission criteria. Goals include the following:
- Ensure appropriate evaluation of the etiology.
- Reassess and address the course the illness takes in its progression.
- Provide any intervention or treatment indicated based on the specific etiology and the course it follows in that specific patient.
- Inpatient care may be necessary, based on the type and/or etiology of acute glomerulonephritis (eg, shunt nephritis), the extent of renal involvement, or the existence of signs and symptoms indicative of potentially serious complications (eg, pulmonary edema, severe hypertension, encephalopathy).
Further Outpatient Care
- Urinalysis at 2, 4, and 6 weeks and at 4, 6, and 12 months
- Cessation of follow-up care when urinalysis is normal
- Blood pressure monitoring during each visit
- Serum creatinine level monitoring at 2, 6, and 12 months
- Serum complement usually normal by 6 weeks
Deterrence/Prevention
- Early penicillin therapy does not prevent development of acute poststreptococcal glomerulonephritis. Although antibiotic therapy should be administered to abolish the streptococcal infection, no evidence indicates that such therapy influences the course of glomerulonephritis. Some clinicians have justified penicillin prophylaxis in populations at risk during epidemics and in siblings of index cases; however, epidemiologic evidence does not favor such use.
Complications
- Progression to sclerosis is rare in the typical patient; however, in 0.5-2% of patients with acute glomerulonephritis, the course progresses toward renal failure, resulting in kidney death in a short period.
- Abnormal urinalysis (ie, microhematuria) may persist for years.
- Marked decline in glomerular filtration rate is rare.
- Other complications, resulting in relevant end-organ damage in the central nervous and cardiopulmonary systems, can develop in patients who present with severe hypertension, encephalopathy, and pulmonary edema. Those complications include the following:
- Hypertensive retinopathy
- Hypertensive encephalopathy
- Rapidly progressive glomerulonephritis
- Chronic renal failure
- Nephrotic syndrome
Prognosis
- In poststreptococcal nephritis, the long-term prognosis generally is good. More than 98% of individuals are asymptomatic after 5 years, with chronic renal failure reported 1-3% of the time.
- The prognosis for nonstreptococcal postinfectious glomerulonephritis depends on the underlying agent, which must be identified and addressed.
- Generally, the prognosis is worse in patients with heavy proteinuria, severe hypertension, and significant elevations of creatinine level.
- Other causes of acute glomerulonephritis have outcomes varying from complete recovery to complete renal failure. Prognosis depends on the underlying disease and the overall health of the patient.
- Occurrence of cardiopulmonary or neurologic complications worsens the prognosis.
Patient Education
- Upon discharge from the ED, patient education should emphasize the importance of close follow-up care.
- Indicate that strenuous exercise should be avoided because exercise can induce proteinuria, hematuria, and cylindruria (renal cylinders or casts in the urine) in healthy individuals.
- Limit the patient to a diet with no added salt until edema, hypertension, and azotemia clear.
- Restrict fluids in patients with significant edema.
- Restrict protein in the presence of azotemia and metabolic acidosis (ie, approximately 0.5 g/kg/d).
- The patient should avoid high-potassium foods.
- For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Blood in the Urine.
Miscellaneous
Medicolegal Pitfalls
- Failure to detect an underlying complicated course or infectious etiology
- Failure to address in a timely manner any of the severe complicated presentations, such as severe hypertension, encephalopathy, or pulmonary edema
- Failure to consider acute glomerulonephritis in the differential diagnosis of patients with early signs, symptoms, or findings, such as mild headaches, flank pain, hematuria, proteinuria, facial edema, or renal insufficiency
- Failure to document patient education given regarding the importance of close follow-up care before discharge from the ED
Special Concerns
- Pediatric patients
- Long-term studies on children with poststreptococcal acute glomerulonephritis have revealed few chronic sequelae.
- Results of such studies are controversial because homogenous populations suitable for proper epidemiologic analysis have not been assembled.
- Elderly patients
- Long-term studies show higher mortality rates in elderly patients, particularly those on dialysis.
- Patients may be predisposed to crescent formation.
The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, A Antoine Kazzi, MD, and Arash David Tehranzadeh, MD, to the development and writing of this article.
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Further Reading
Keywords
acute glomerular nephritis, acute hemorrhagic glomerulonephritis, acute glomerulonephritis, acute nephritis, poststreptococcal nephritis, acute poststreptococcal glomerulonephritis, nephritic syndrome, acute nephritic syndrome, nephritis syndrome, acute nephritis syndrome, kidney disease, renal disease, hematuria, oliguria, anuria, proteinuria
hypertension, malignant hypertension, edema, impaired renal function, puffiness of the eyelids, facial edema, postinfectious acute nephritis, pharyngitis, postpharyngitis, postdermal infection, Berger disease, Wegener granulomatosis, Henoch-Schönlein purpura, systemic lupus erythematosus, arthralgias, hemoptysis
Goodpasture syndrome, idiopathic progressive glomerulonephritis, hypersensitivity vasculitis, cryoglobulinemia, hypertensive encephalopathy, hypocomplementemia, scarlet fever, impetigo, upper respiratory infection, visceral abscesses, endocarditis, infected grafts, infected shunts, pneumonia, cytomegalovirus, coxsackievirus, Epstein-Barr virus, hepatitis B, rubella, rickettsial scrub typhus, mumps, polyarteritis nodosa, membranoproliferative glomerulonephritis, immunoglobulin G-immunoglobulin Anephropathy, IgG-IgA nephropathy
