ACUTE GLOMERULONEPHRITIS

Case
Kate, a 10 year old grade – schooler was diagnosed with Acute
Glomerulonephritis. Tests have been administered and it was found out that there was
an active urinary segment. This means that there are signs of active kidney
inflammation.

Overview of the Disease

Acute glomerulonephritis (AGN) is active inflammation in the glomeruli. Each

kidney is composed of about 1 million microscopic filtering "screens" known as glomeruli
that selectively remove waste products. The inflammatory process usually begins with
an infection or injury such as a burn, or trauma then the protective immune system fights
off the infection, scar tissue forms, and the process is complete.

Acute glomerulonephritis occurs frequently in children as a result of the delayed

hypersensitivity reaction initiated by infectious agents like streptococci, often identified
as causing tonsillitis or scarlet fever 1-2 weeks before the disease develops. All post
infectious diseases are presumed to result from immune complex formation and
glomerular deposition, and the clinical presentations may be indistinguishable. This can
occur at any age but primarily affects early school – age children. It is uncommon in
children younger than 2 years of age.

Acute Glomerulonephritis (AGN) as a classification includes a number of distinct

entities. It may be a primary event or a manifestation of a systemic disorder, and the
disease can range from minimum to severe. The common features include oliguria,
edema, hypertension and circulatory congestion, hematuria and proteinuria.

Majority of the patients recover completely; 5-10% progress to nephritic

syndrome and chronic nephritis.

Anatomy and Physiology

The kidneys are a pair of bean-shaped organs with the inner border of hilum
directed towards the vertebral column. Each kidney is surmounted by a suprarenal
(adrenal gland). A thin capsule of fibrous tissue surrounds each kidney, forming a
smooth covering. Beneath this, the kidney substance lies which is of a deep purple color
and consists of an outer cortical part and an inner medullary part. The latter is made up
of fifteen to sixteen pyramid-shaped masses, the pyramids of the kidney. The apices of
these are directed towards the hilum, and open into calyces which communicate with the
pelvis o the kidney.

The minute structure of the kidney is composed of one to one and a half millions
of nephrons – the functional units of the kidney. The nephron consists of a tuft of blood
vessels, the glomeruli surrounded by the Bowman’s capsule. To each capsule is
attached a long tubule, including a convoluted tubule terminating in the loop of Henle,
and an ascending loop that ultimately connects with a main collecting tube opening into
the renal pelvis.
When blood passes through the glomerular capillaries of the nephron, filtration
occurs. A protein-free filtration passes through the tubular segments of the nephron and
the cells absorb those substances which the body wants and leave behind those that are
not wanted. The glomeruli filter 170 liters of solution a day but the volume of urine
excreted in a day is about 1.5 liters, reabsorbing 99% of the glomerular filtrate in the
tubules. In the lower portion (distal) of the tubules, concentration of urine takes place
and this requires energy. There is also a flow of substances from plasma directly across
the tubular cells into the lumen of the tubule. Glucose under normal conditions is
completely reabsorbed along the proximal length of the tubules, whereas creatinine,
urea and some of the salts are filtered both via the glomeruli and also via the proximal
tubules to join the urine.

RENAL FUNCTION
The kidney has basically three broad functions, that of:
1. Excretion – where excess water, useless or harmful materials are removed or cleared
and where certain excess catabolic products such as urea, uric acid (as urates),
creatinine and various salts such as nitrates, sulfates and phosphates are eliminated.
Dead and dying renal cells, minute amounts of protein especially mucoproteins and
ingested poisons are expelled. When the renal threshold for a certain substance is
exceeded, the excess is excreted in the urine. Ex: when blood glucose reached a level
of 180 mg %, any excess above the level is excreted.
2. Homeostasis and metabolism – related to the first function, useful substances
necessary for physiologic functions are conserved through reabsorption. When these are
not in excess of bodily needs, i.e., glucose, amino acids, ions such as Na, K, Mg, Ca, P,
vitamins, etc. The kidney also maintains acid-base and electrolyte balance and normal
nutrition.
3. Endocrine – primarily deals with hormones secreted by the organ like renin,
erythropoietin and prostaglandins.
If the kidneys are diseased, the kidneys are not able to perform their functions
well and there are certain methods which will be helpful in locating the site of impairment
of renal function and which will also add to our information concerning the normal
biochemical function of the cells of the kidney. Of these the most useful are:
1) Testing the urine for albumin or protein. If the glomeruli or tubules are
damaged, protein leaks into the urine.
2) Measuring the blood urea concentration. If the kidneys are not excreting
enough urea, the blood urea rises above the normal value of 25-40 mg %.
3) Determining the urine to plasma ratio as an index of concentrating and
absorbing capacity of the kidneys.
4) The urinary deposit may be examined for red blood cells and casts, etc.

DISEASES OF THE KIDNEY

Any damage to the kidney might interfere with one or all functions of the kidney
depending upon the extent of the damage. With destruction of less than 50% of the
nephrons, the kidneys are sstill able to carry on with the work load that they are
subjected to. With 60% or more, renal failure sets in manifested by azotemia, anemia,
electrolyte imbalance and acidosis. Nephritis is the term used to describe a group of
non-infective kidney diseases representing three broad types: acute glomerulo-nephritis,
nephritic syndrome and chronic nephitis.
Cause

It is now generally accepted that Acute Glomerulonephritis is an immune –

complex disease (it is a reaction that occurs as a by – product of an antecedent
streptococcal infection with certain strains of the group A ß – haemolytic streptococci. A
latent period of 10 to 14 days occurs between the streptococcal infection of the throat or
skin and the onset of clinical manifestations.

Post infectious etiologies

• The most common cause is post infectious Streptococcus species.
• Other specific agents include viruses and parasites, systemic and renal disease,
visceral abscesses, endocarditis, infected grafts or shunts, and pneumonia.
• Bacterial causes other than group A streptococci may be diplococcal,
streptococcal, staphylococcal, or mycobacterial. Cytomegalovirus, rubella, and
mumps are accepted as viral causes only if it can be documented that a recent
group a ß - haemolytic streptococcal infection did not occur.
• Fungal and parasitic: Attributing glomerulonephritis to a parasitic or fungal
etiology requires the exclusion of a streptococcal infection

Signs and Symptoms

The onset of AGN appears as after an average latent period of approximately 10

days. Initial signs of nephritic reaction include puffiness of the face, especially around
the eyes (periorbital edema); anorexia and the passage of dark – colored urine.

Overall Appearance
The child is pale, irritable and lethargic, and unwell and appears unwell but seldom
expresses specific complaints.

Edema
The edema is more prominent in the face in the morning but spreads during the day to
involve the extremities and abdomen.

Oliguria, Dysuria, Azotemia and Hematuria

The disease may be characterized by hematuria and albuminuria (due to the
damage of the renal filtering mechanism) resulting in a cloudy urine.

The urine is cloudy, smoky brown, or what parents describe as resembling cola
or tea, and it is severely reduced in volume. A diminished output of urine or oliguria
causes retention of waste products as a result of reduced glomerular filtration rate.

Hematuria is a universal finding, even if it is macroscopic. Older children may

complain of dysuria or pain when urinating.

Hypertension
 Hypertension occurs as a result of circulatory congestion because of damaged
blood vessels in the kidney. Upon examination, there is usually a mild to moderate
elevation of blood pressure compared with normal values for age. Headache may occur
secondary to hypertension.

Seizures
Occasionally, a child will have an onset with severe symptoms such as seizures
from hypertensive encephalopathy, pulmonary and circulatory congestion or hematuria
in the absence of hypertension and edema.

Other Signs and Symptoms

Older children may complain of abdominal discomfort due to the stretching of the
renal capsule. Skin rashes may also be observed. Other signs include: Pharyngitis,
Impetigo, Respiratory infection, pulmonary hemorrhage, Heart murmur that may indicate
endocarditis, Weight gain, Anorexia, Back pain and Skin pallor.

Tests and Diagnosis

• Urinalysis - test to look for blood, protein, bacteria, and other evidence of kidney
damage in the urine. Gross discoloration of urine reflects its red blood cell and
haemoglobin content. Microscopic examination of the sediment shows many red
blood cells, leukocytes, epithelial cells and granular red blood cell casts.

• Blood Test - tests to check how well the kidneys are functioning. Unless the
disease has progressed to renal failure, blood examination reveals normal
electrolyte levels. Azotemia resulting from impaired glomerular filtration is
reflected in elevated blood urea nitrogen and creatinine levels.

• Cultures of the pharynx are positive for streptococci in only a few cases.

• Serologic tests are necessary for diagnosis. Antibody responses to the

extracellular products of the streptococci provide indirect evidence of previous
streptococcal infection. The antistreptolysin O (ASO) titer is the most familiar test
for streptococcal antibodies. ASO appears in the serum approximately 10 days
after the initial infection. An ASO titer of 250 Todd Units or higher is of diagnostic
significance.

• Chest X – ray examination – shows generalized cardiac enlargement, pulmonary

congestion, and pleural effusion during the edematous phase.

• Kidney biopsy - removal of a sample of kidney tissue with a needle to test for
glomerulonephritis. This is seldom required but may be useful for atypical cases.
Treatment and Drugs

The goal of treatment is to stop the ongoing inflammation and lessen the degree
of scarring that follows. Often the treatment warrants a regimen of immunosuppressive
drugs to limit the immune system’s activity. This decreases the degree of inflammation
and subsequent irreversible scarring.

Management consists of general supportive measures: Bed rest is no longer

recommended during the acute phase because ambulation does not seem to have an
adverse effect on the course of the disease once the hematuria, edema, hypertension
and azotemia have become less.

Diuretic Medications
Diuretics such as Furosemide (Lasix) may be prescribed to help the kidneys
excrete excess sodium and water.

Antibiotics
If infection is present, penicillin administration is recommended.

Immunosuppressants
For rapidly progressive glomerulonephritis, drugs to suppress the immune
system are started promptly. High doses of corticosteroids such as Prednisone, and
Methylprednisolone have anti-inflammatory effects and are immunosuppressive.
Cyclophosphamide, an immunosuppressant, may also be given. The sooner treatment is
given; the less likely are kidney failure and the need for dialysis to occur.

Anti – hypertensive drugs

Angiotensin - converting enzyme (ACE) inhibitors and angiotensin II receptor
blockers (ARBs), either alone or in combination, often slows progression to chronic
glomerulonephritis. Taking drugs to reduce high blood pressure and reducing sodium
intake are considered beneficial.

Kidney dialysis
Dialysis may be required for short-term or long-term therapy. Dialysis is a
medical treatment to remove wastes and additional fluid from the blood after the kidneys
have stopped functioning. Kidney transplantation is sometimes considered for people
who develop chronic kidney failure, but rapidly progressive glomerulonephritis may recur
in the transplanted kidney.
Nutritional Therapy

If nausea and vomiting are present, a diet adequate in all nutrients will be difficult
to provide. Calories in the form of sweetened fruit juices, sweetened tea and hard
candies should be supplied to minimize tissue catabolism. As the condition improves,
the following are suggested:

ENERGY The caloric needs of the patient should be provided by carbohydrate and
fat to spare the tissues from being used up as a source of energy.
Calories from fats should be supplied by monounsaturated fat sources
such as avocado and olive oil and polyunsaturated fat sources such as
salmon, soybeans and fish oil.

PROTEIN The body uses protein for the growth and repair of tissues. Normally,
protein by - products are excreted from the body in the urine. When
kidney function is impaired, the end products of protein metabolism, urea,
accumulates in the bloodstream. The best kind of protein to eat is the kind
that is used most efficiently by the body. Doing this leaves the least
amount of protein waste behind. These proteins are referred to as
complete or high quality proteins that contain all the essential amino
acids. Many clinicians are still a disagreement whether to restrict or not to
restrict protein. If there is nitrogen retention, since the waste products
of protein breakdown cannot be excreted, protein is restricted to 0.5 gm
protein per kilogram body weight or about 30 grams per day for adults. If
a need for protein restriction arises in children, an amount of 50% of the
recommended dietary allowances (RDA) is suggested. When there is
marked proteinuria, protein intake should be increased to compensate for
protein lost in the urine. In which case, protein sources in the diet should
come chiefly from sources of high biologic value.

SODIUM The balance of fluid in the human body is partly regulated by the mineral
sodium. When sodium is combined with chloride, it forms table salt.
Excessive amounts of salt in the diet result in the retention of too much
water. Salt (sodium) is restricted to improve blood pressure control, limit
the possibility of developing hypertension, as well as to minimize or
prevent retention of fluids that leads to swelling. About 1 gram sodium per
day is recommended. This is necessary when edema is present as a
result of the adrenal stimulation and also to prevent dangers of
hypertension, congestive heart failure and pulmonary edema. Add flavour
into foods with lemon, herbs and spices rather than adding salt.

POTASSIUM One gram per day restriction is necessary if there is potassium retention
the degree of which is roughly proportional to the urine output.
FLUID Fluids are defined as all liquids, including all foods that melt to a liquid at room
temperature. Water soluble fruits such as grapes, oranges, apples,
lettuce and celery also contribute to fluid count. When the water excretory
function of the kidney becomes limited, excess intake of fluid will result in
more edema. In mild cases, fluid restriction is not necessary. In severe
cases, the amount given in 500cc (insensible fuid loss) plus the amount of
urine passed in the previous 24 hours. Larger amounts may be necessary
if there is vomiting, diarrhea or excessive perspiration. Keeping track of
the patient’s weight every day can allow early detection of any trend of
fluid retention.

PHOSPHORUS Acute glomerulonephritis patients may have difficulty excreting

phosphorus leading to a build - up of dangerously high phosphorus levels
in the body. Increased levels can lead to heart and bone diseases.
Phosphorus intake should be limited to between 800 and 1,000 mg per
day. Phosphorus is present in dairy products such as milk, ice cream and
yogurt. Peas, beans, peanut butter and nuts are also sources of
phosphorus that need to be monitored. Additives containing phosphorus
are routinely added to processed and fast foods to enhance flavour and
extend shelf life. Avoid beverages such as cola drinks, cocoa and beer.
As soon as the edema is reduced, the blood pressure lowered, and the
urine output increased, a normal diet may be provided.

Vitamin and mineral supplements are frequently needed since dietary restrictions
may prevent an AGN patient from receiving all the needed nutrients necessary for a
healthy and balanced diet. Kidney dialysis can also remove vitamins from the
bloodstream.
Diet Computation

Name of Patient: Kate

Age: 10 years old

I. Desirable Body Weight

DBW = (no. of years * 2) + 8
= (10 * 2) + 8
= 20 + 8
= 28 kg

II. Total Energy Requirement

TER = 1, 000 + (age in years * 100)
= 1, 000 + (10 * 100)
= 1, 000 + 1, 000
= 2, 000 calories/day

III. Percentage Distribution

% C = 2, 000 * .65 = 1, 300/4 = 325 grams
% Pro = 2, 000 * .08 = 160/4 = 40 grams
% F = 2, 000 * .27 = 540/9 = 60 grams

IV. Composition of Food Exchange List

List Food Measures No. of CHO4 PRO4 F9 CALORIES

No. Groups Exchange
I. A. Vegetable ½ cup 3 9 3 - 48
A cooked
II. Fruits Varies 3 30 - - 120
III. Full ½ gram 1 12 8 10 170
Cream undiluted
Milk
IV. Sugar 1 tsp. 9 45 - - 180
V. Rice Rice 4 92 8 - 400
Rice 6 138 12 - 600
equivalent
VI. Meat Varies
Low fat 1 - 8 1 41
Medium 1 - 8 6 86
Fat
VII. Fat 1 tsp. 9 - - 45 405
326 47 62 2, 050
Menu Plan (1 Day Sample)

BREAKFAST
Fruit cocktail – ½ cup drained
Omelette
Egg – ½ egg
Potato – ½ cup
Tomato – ½ cup
Oil – 2 tsp.
Toasted Bread with Jam
Bread – 2 slices
Jam – 2 tsp.
Sugar – 2 tsp.
Oil – 2 tsp.
Milk
Sugar – 1 tsp.

LUNCH

Lean pork tinola

Pork – 1” cube
Sayote – ½ cup
Oil – 1 tsp.
Palitaw – 2 pcs.
Grated coconut – 2 tbsp.
Sugar – 2 tsp.
Rice – 1 cup
Kaimito
2 glasses of water

DINNER

Upo picadillo
Ground pork – 1 tbsp.
Upo – ½ cup
Oil – 2 tsp.
Kamote Fries
Kamote – 1 m.s.
Oil – 1 tsp.
Sugar – 2 tsp.
Rice – 1 cup
Mango – 1 slice
2 glasses of water
Recipes

Omelette with potato and tomato

Ingredients:
½ egg
½ cup of potato, peeled, diced small
½ cup of tomato
1 teaspoon olive oil
pepper
parsley

Cooking procedure:
Boil the potato for 5 minutes in water. Drain off water. Mix with the eggs. Beat the egg
very lightly; add the tomato, pepper and spices. Melt the butter in a pan and add the
mixture. As soon as it begins to stiffen, draw it away from the edges of the pan or gently
slide a knife under the center to allow the uncooked egg to reach the hot pan and cook
evenly. When the omelet is a rich golden brown, fold over and serve at once on a very
hot plate.

Toasted bread with Jam

Ingredients:
Jam
2 slices bread
2 teaspoons olive oil
2 teaspoons jam
2 teaspoons sugar

Procedure:
Heat the butter in a pan. Toast the bread until it is golden brown. Place jam into the
bread and add sugar.

Pork tinola

Ingredients:
Pork – 1” cube
Sayote – ½ cup
Oil - 1 tsp
1 clove of garlic
pepper
1cup of water

Cooking procedure:
Crush garlic and discard skin. Heat cooking oil in a large saucepan or casserole. Over
high heat, saute garlic until fragrant, about 1 minute. Add pork cube and cook, stir, until
no longer pink on all sides. Season with pepper. Pour in the water and bring to a boil.
Lower heat, cover and simmer for 45 minutes.
Meanwhile, remove skin of sayote with a sharp knife or a vegetable peeler. Cut in half
lengthwise and remove the white core with a knife. Cut into wedges. About 15 minutes
before the pork is fully cooked, increase heat to high and add the sayote wedges. Bring
to a boil, cover and simmer until sayote is cooked. Turn off heat, cover for 5 minutes.
Serve hot.

Palitaw

Ingredients:
½ cup of Malagkit
4 cups of boiling water
2 tsp. of white sugar
2 tbsp. of grated coconut

Cooking procedure:
Boil about 4 cups of water in a large saucepan or casserole. Take a teaspoonful of the
malagkit and flatten it with your hands. Drop in the briskly boiling water. Cook a few
pieces at a time. As soon as the dough rises to the surface, lift it out with a slotted spoon
and roll in niyog (grated coconut). Repeat until all the dough has been cooked. Serve
with the sugar.

Upo Picadillo

Ingredients:
2 teaspoons oil
1 tablespoon of ground pork
1 cup beef stock or water
½ cup upo
Pepper

Cooking procedure:
Heat oil in a casserole or large saucepan, 1 to 2 minutes. Stir in ground pork. Pour in
stock or water and bring to the boil then simmer over medium heat. Add diced upo and
simmer until upo is tender, about 10 minutes. Season with pepper

Kamote Fries

Ingredients:
1 medium sized kamote
2 tsp. oil
3 tsp. sugar

Cooking procedure:
Heat oil in a pan and fry the kamote cut into wedges. Cook until golden brown. Sprinkle
with sugar.

Lifestyle Changes

• Restrict salt and water intake.

• Restrict intake of potassium, phosphorous, and magnesium.
• Cut down on protein in the diet.
• Maintain a healthy weight through diet and exercise.
• Take calcium supplements.

Prevention

• There is no way to prevent most forms of acute glomerulonephritis. However,

here are steps that may be beneficial:
• Seek prompt treatment of a strep infection causing sore throat impetigo.
• Control the blood sugar to help prevent diabetic nephropathy.
• Control the blood pressure, which lessens the likelihood of damage to the
kidneys from hypertension.
 Our Lady of Fatima University
COLLEGE OF NURSING
Antipolo City

ACUTE GLOMERULONEPHRITIS

In Partial Fulfillment
Of the Requirements In
Nutrition and Dietetics

Submitted by:
Bautista, Mary Kristine S.
Delos Santos, Marie Bernadette R.
De Leon, Alyssa Dawn
Velasco, Patrick Benedict

Submitted to:
Mrs. Gonzales
 Date:
May 20, 2010