eMedicine Specialties > Emergency Medicine > Genitourinary
Glomerulonephritis, Acute: Treatment & Medication
Updated: Oct 2, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
- In most patients, acute glomerulonephritis is not an acute life-threatening emergency if the patient has normal vital signs and lacks underlying illness.
- Give highest priority to patients who present with hypertension or pulmonary or CNS symptoms.
Emergency Department Care
ED treatment is etiology dependent.
- Correction of electrolyte abnormalities (ie, hypocalcemia, hyperkalemia) and acidosis, if present.
- Poststreptococcal
- Eradicate streptococcal causes by oral antibiotic therapy.
- Penicillin is indicated in nonallergic patients. Note that early antibiotic therapy does not affect the development of poststreptococcal glomerulonephritis.
- Admit patients who present with oliguria and renal failure.
- Consider renal biopsy.
- Acute nephritic syndrome
- Restrict fluids in patients with significant edema.
- Loop diuretics are indicated for patients with nephrotic syndrome (4% of patients) or massive proteinuria.
- Consider admission for patients with underlying compromised renal function or immunosuppression.
- Admission is recommended for patients with anuria, nephrotic syndrome, massive proteinuria, significant hypertension, or pulmonary symptoms.
- Hypertensive encephalopathy
- Severe hypertension associated with signs of cerebral dysfunction is a hypertensive emergency requiring immediate aggressive treatment.
- Manifestations include headache, nausea/vomiting, blurry vision, seizures, and coma.
- Address the airway first. Intubation may be required for patients who present with severe CNS depression, signs of active or impending herniation, or status epilepticus.
- Although use of diazoxide and hydralazine often is described, neither commonly is used.
- Base treatment of hypertensive emergencies upon the specific organ involved. Tailor therapy to the depressed renin states and the degree of renal insufficiency.
- Severe hypertension with or without end-organ insufficiency
- Agents useful in treating hypertension include calcium channel blockers and nitroprusside. Note that beta-blocking agents or angiotensin-converting enzyme (ACE) inhibitors administered alone may not be useful unless administered with vasodilators and diuretics, because plasma renin activity levels are reduced.
- In most patients with less severe hypertension, captopril should decrease blood pressure in less than 1 hour. Note that since renin activity is depressed, use of captopril carries the risk of hyperkalemia. Monitor serum potassium level closely.
- Circulatory congestion and pulmonary edema
- The patient often presents with only mild edema. In this setting, the most effective treatment is sodium and fluid restriction.
- Diuretics such as furosemide are effective in more advanced disease; however, potassium-sparing diuretics are contraindicated because of an increased risk of hyperkalemia.
- Manage the airway based upon the degree of pulmonary congestion and respiratory distress.
- Dialysis or bloodless phlebotomy (rotating tourniquets) can be used to treat patients with pulmonary edema who are unresponsive, particularly when those patients are oliguric.
- Digitalis is ineffective.
- Preload and afterload reductions are indicated for hypertensive pulmonary edema (eg, nitrates, morphine, diuretics).
- Therapies in nonstreptococcal glomerulonephritis: Steroids and cytotoxic agents may be indicated in the following conditions:
- Glomerulonephritis secondary to hypersensitivity
- Vasculitis
- Cryoglobulinemia
- Henoch-Schönlein purpura
- Serum sickness: First-line therapy includes nonsedating antihistamines such as cetirizine, astemizole, loratadine, desloratadine, terfenadine, and acrivastine. In nonresponsive patients, a short course of oral steroids may be indicated as a second-line treatment.
- Systemic lupus erythematosus: Pulse therapy with methylprednisolone has been reported to be more rapidly effective than conventional oral therapy for treating lupus nephritis.
- Wegener granulomatosis: Oral cyclophosphamide, an antineoplastic immunosuppressant, is combined with oral steroid therapy. Such therapy is beyond the scope of ED care. Cyclophosphamide is continued until clinical remission, while steroids are tapered over 6 months to 1 year. Adjunctive use of azathioprine has also been described.
- Idiopathic rapidly progressive glomerulonephritis: Pulse intravenous methylprednisolone is used to reduce risk of progression to end-stage renal disease. Cyclophosphamide is also used in conjunction with steroids. Dialysis should be considered to remove antigen-antibody complexes in patients with biopsy-proven, extensive, and irreversible glomerular and interstitial damage.
- Goodpasture syndrome: Plasmapheresis is combined with immunosuppression (ie, prednisone and cyclophosphamide). High-dose pulse steroids are effective for pulmonary hemorrhage.
- Disposition: ED physicians should have a low threshold for admitting patients with suspected acute glomerulonephritis. Patients who present with hematuria only without renal impairment, elevations in BP, hemoptysis, or any other concerning symptoms can be sent home with thorough follow-up instructions and close follow-up with a nephrologist.
Consultations
- A nephrologist may need to be consulted immediately for dialysis of the rare oliguric patient.
- Urgency for referral depends on the GFR; if the GFR is abnormal or rapidly deteriorating, or if systemic symptoms are present, immediate consultation is indicated.
- Consultations are often indicated in the evaluation and follow-up care of patients with glomerulonephritis.
- Surgical referral for biopsy is indicated in selected cases.
Medication
Treatment involves specific pharmacologic and supportive therapy to prevent and/or treat the sequelae, such as edema, hypertension, and progression of renal disease.
Antibiotics
Therapy must cover all likely pathogens in the context of the clinical setting. Penicillin is the DOC in treating acute glomerulonephritis of a poststreptococcal group A beta-hemolytic etiology.
Penicillin V (Veetids)
Derivative of 6-aminopenicillanic acid with a beta-lactam ring structure essential for bactericidal activity. Inhibits enzymes and cell wall receptors, resulting in cell wall synthesis inhibition. Other autolytics enzymes are also activated, degrading the bacterial cell wall. Bacterial resistance via beta-lactamase can be prevented with addition of clavulanic acid, sulbactam, or tazobactam. Other forms of bacterial resistance include alteration of bacterial PBPs and decreased permeability of cell wall to penicillin.
Adult
500 mg PO q6h
Pediatric
<12 years: 40 mg/kg/d PO divided q4-6h; not to exceed adult dose
>12 years: Administer as in adults
Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing decrease in effectiveness of penicillins when administered concurrently
Documented hypersensitivity; renal function impairment; bleeding disorder; congestive heart failure; cystic fibrosis; GI disease or antibiotic-associated colitis; mononucleosis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal impairment
Nonselective beta-blocker with cardioselective alpha1 blocker
Labetalol is used for hypertensive encephalopathy and malignant hypertension.
Labetalol (Normodyne)
Has nonselective beta-antagonist and cardioselective alpha1-antagonist effects. Beta-blocking effects predominate, particularly when used IV. Low lipid solubility means bioavailability is reduced by first pass metabolism and enhanced by coadministration of food. Drug is not removed by hemodialysis.
Adult
20 mg (0.25 mg/kg for 80-kg patient) IV microdrip labetalol hydrochloride injection slowly over 2 min; desired BP may be achieved with continued injections of 40-80 mg at 10-min intervals or until 300 mg has been administered prn; to reduce possibility of postural hypotension, patients should remain supine for 3 h after administration
Pediatric
Not established
Suggested dose: 0.4-1 mg/kg/h IV; not to exceed 3 mg/kg/h
Decreases effect of diuretics and increases toxicity of methotrexate, lithium, and salicylates; may diminish reflex tachycardia, resulting from nitroglycerin use, without interfering with hypotensive effects; cimetidine may increase labetalol blood levels; glutethimide may decrease labetalol effects by inducing microsomal enzymes
Documented hypersensitivity; cardiogenic shock; atrioventricular block; uncompensated congestive heart failure; pulmonary edema; bradycardia; reactive airway disease; severe bradycardia
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired hepatic function; discontinue therapy if signs of liver dysfunction; in elderly patients, lower response rate and higher incidence of toxicity may be observed
Loop diuretics
Loop diuretics are used for hypertensive encephalopathy with CNS signs and circulatory congestion or pulmonary edema. Furosemide is DOC for this indication.
Furosemide (Lasix)
Inhibits resorption of sodium and water in ascending limb of loop of Henle by interfering with Na+/K+/Cl- channel. An antihypercalcemic effect is mediated by an increased excretion of calcium.
Plasma volume, blood pressure, and cardiac output are reduced. Calcium excretion is increased.
Absorption of oral furosemide is reduced with renal disease or nephrotic syndrome as a result of edematous bowel. Parenteral administration may be indicated in patients with compromised kidneys; metabolized by hepatic biotransformation and renal excretion; onset of action is 20-60 min PO and 5 min IV. Children with nephrotic syndrome may require higher dosing beyond the scope of ED care.
Adult
20-80 mg PO/IV once initially, followed by once qd, or once qod after titrating for optimum efficacy, or by dividing daily dose bid/tid
Pediatric
Initially: 2 mg/kg PO/IV once; titrate with additional 1-2 mg/kg q6h
Metformin decreases furosemide concentrations; furosemide interferes with hypoglycemic effect of antidiabetic agents and antagonizes muscle-relaxing effect of tubocurarine; auditory toxicity appears to be increased with coadministration of aminoglycosides and furosemide (hearing loss of varying degrees may occur); anticoagulant activity of warfarin may be enhanced when taken concurrently; increased plasma lithium levels and toxicity are possible when taken concurrently
Documented hypersensitivity; hepatic coma; anuria; renal function impairment; diabetes mellitus; gout; MI; pancreatitis; state of severe electrolyte depletion
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Perform frequent serum electrolyte, carbon dioxide, glucose, creatinine, uric acid, calcium, and BUN determinations during first few months of therapy and periodically thereafter
Corticosteroids
Methylprednisolone is used for nonstreptococcal etiologies of acute glomerulonephritis, particularly in lupus nephritis and in idiopathic progressive glomerulonephritis.
Methylprednisolone (Medrol)
Has anti-inflammatory effect and is immunosuppressive. Metabolized by hepatic transformation and renal excretion.
Adult
Pulse therapy of 30 mg/kg IV over minimum of 30 min
Pediatric
Administer as in adults
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adverse effects include allergy, cataracts, Cushing syndrome, severe acne, GI irritation, and pancreatitis
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use
Antineoplastics and immunosuppressants
Cyclophosphamide is used for etiology-dependent treatment of acute glomerulonephritis due to Wegener granulomatosis.
Cyclophosphamide (Cytoxan, Neosar, Procytox)
Acts as alkylating agent that cross-links strands of DNA and RNA. Other actions include inhibition of protein synthesis, immunosuppression, and cholinesterase inhibition. Not within the scope of ED care.
Adult
For long-term therapy, the following doses are used:
400-1800 mg/m2 (30-40 mg/kg) IV in divided doses over 2-5 d; may repeat at 2- to 4-wk intervals; alternatively, 10-15 mg/kg IV q7-10d or 3-5 mg/kg twice weekly
Pediatric
Long-term therapy: Administer as in adults
Allopurinol may increase risk of bleeding or infection and enhance myelosuppressive effects; may potentiate doxorubicin-induced cardiotoxicity; may reduce digoxin serum levels and antimicrobial effects of quinolones
Chloramphenicol may increase half-life while decreasing metabolite concentrations; may increase effect of anticoagulants; coadministration with high doses of phenobarbital may increase rate of metabolism and leukopenic activity; thiazide diuretics may prolong cyclophosphamide-induced leukopenia and neuromuscular blockade by inhibiting cholinesterase activity
Documented hypersensitivity; severely depressed bone marrow function
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Regularly examine hematologic profile (particularly neutrophils and platelets) to monitor for hematopoietic suppression; regularly examine urine for RBCs, which may precede hemorrhagic cystitis
More on Glomerulonephritis, Acute |
| Overview: Glomerulonephritis, Acute |
| Differential Diagnoses & Workup: Glomerulonephritis, Acute |
 Treatment & Medication: Glomerulonephritis, Acute |
| Follow-up: Glomerulonephritis, Acute |
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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
