Approach Considerations
Medical care for glomerulonephritis (GN) is usually divided into 2 major components: treatment of primary pathology and supportive care. In renal diseases, supportive care involves managing hypertension and fluid and electrolyte abnormalities and managing decreased renal function.
The treatment of primary pathology ranges from watchful waiting, as in postinfectious GN, to treatment with immunosuppressive medication, such as steroids or cyclophosphamide in lupus. To discuss the primary treatment of all forms of nephritis is beyond the scope of this article. In the case of some etiologies for GN, for example, IgM nephropathy, no definitive therapy is known.
Hypertension can be managed with antihypertensives, such as calcium channel–blocking agents, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor–blocking agents, peripheral vasodilators, and diuretics. The most common fluid abnormality, hypervolemia, is managed with fluid restriction and diuretics or with dialysis if renal function is too poor to respond to diuretics. Hyponatremia is usually dilutional and responds, at least partially, to removal of excess fluid. Hypocalcemia may respond to oral or IV calcium, depending on severity. Mild metabolic acidosis may be present but rarely requires primary treatment.
Some recommend a short course of steroids or cyclophosphamide for tubulointerstitial nephritis (TIN). Prednisone may speed up the recovery from renal symptoms of TIN. [9] However, these drugs are usually not necessary. Most often, stopping the offending agent leads to recovery.
Consultations
Primary care physicians can usually manage children with poststreptococcal GN unless dialysis is imminent. If dialysis access is necessary, consultation with a surgeon may be required. Refer children with other forms of GN or TIN to a pediatric nephrologist.
Inpatient care
Inpatient care is usually necessary only to manage severe hypertension or complications of acute or chronic renal failure (eg, dialysis access, uremic syndrome, congestive heart failure, electrolyte abnormalities such as hyperkalemia and pericardial effusion). These problems are infrequent in the general pediatric population.
Children with renal failure should be cared for by a physician with experience in managing pediatric renal failure. In the United States, such doctors are frequently found at a tertiary facility.
Outpatient monitoring and care
Outpatient care may be as simple as observation in a child with tubulointerstitial nephritis (TIN) or resolving poststreptococcal glomerulonephritis (GN), or it may involve the use of antihypertensives, diuretics, and diet modification, as in a child with IgA nephropathy or membranoproliferative GN and preserved renal function. Outpatient therapy may involve dialysis in a child who develops end-stage renal disease.
Diet and Activity
In children with acute renal failure secondary to glomerulonephritis (GN) who have lost the ability to excrete a water load, fluid restriction may prevent fluid overload. Tubulointerstitial nephritis (TIN) usually produces nonoliguric acute renal failure. Fluid restriction of 300 mL/m2/d plus losses may allow management of acute renal failure for 2-3 days without dialysis. In patients with hypertension, sodium restriction to the recommended daily allowance (RDA) of 2-4 mEq/kg/d may aid in management. In children with renal failure, potassium restriction is justified to prevent hyperkalemia. Calcium supplementation is useful to maintain normal serum calcium.
In patients with hypertension and renal failure, discourage strenuous activity; however, walking, playing, and other activities are acceptable.
