Chapter I

Introduction

Objectives of the Study:

a. General objectives

The general objective of this case presentation is to foster and develop

knowledge and skills in providing care and management of patient with Acute
Glomerulonephritis

b. Specific objectives

 To define Acute Glomerulonephritis

 To know the clinical manifestation, nursing management and
interventions for patients who have this disease
 To know the different medication for patients with AGN and
know their side effects which can be harmful
 To be able to obtain, document and present a
comprehensive medical history
 To know the pathophysiology of Acute Glomerulonephritis
 To know how AGN is diagnosed and the important
laboratory examinations that will confirm AGN
 To know the nursing priorities to consider when dealing with
patients of AGN
 To be able to recognize the importance of patient and
familial preferences when selecting among treatment options

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DESCRIPTION OF THE CASE

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 uremic waste products. The inflammatory
process usually begins with an infection or injury (e.g., burn, trauma), then the
protective immune system fights off the infection, scar tissue forms, and the
process is complete. Acute glomerulonephritis (AGN) occurs 5 to 21 days after a
streptococcal infection. http://www.nephrologychannel.com/agn/index.shtml

There are many diseases that cause an active inflammation within the
glomeruli. Some of these diseases are systemic (i.e., other parts of the body are
involved at the same time) and some occur solely in the glomeruli. When there is
active inflammation within the kidney, scar tissue may replace normal, functional
kidney tissue and cause irreversible renal impairment.The severity and extent of
glomerular damage—focal (confined) or diffuse (widespread)—determines how
the disease is manifested. Glomerular damage can appear as subacute renal
failure, progressive chronic renal failure (CRF).
http://www.nephrologychannel.com/agn/index.shtml

Acute Glomerulonephritis is a trending health concern to the nursing

profession. From the article, “A Serious Kidney Problem: Kidney Infections and
Causes”, A kidney infection is often a serious kidney problem that should get
prompt medical attention. Treatment usually requires antibiotics and a hospital
stay. If it isn't treated correctly, a kidney infection can result in serious damage to
the kidney failure or spread to your bloodstream and cause a life-threatening
situation. It's typical for a kidney infection to commence somewhere else in the
body - generally the bladder. Germs from the bladder migrate upward in the
ureters and begin to multiply when they reach the kidneys. Kidney infections
often occur in people whose resistance has been lowered, either by an illness or
some other cause like stress and fatigue. There are two main classifications of

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kidney infections and they result from a number of possible kidney problems.The
medical names for a kidney infection are pyelonephritis and glomerulonephritis.A
kidney infection can also be acute or chronic in nature. When you have an acute
infection, the symptoms generally come on quickly and can be severe. But it runs
its course and is over soon. But a chronic infection develops slowly, with few
symptoms, and gets worse as time passes. Kidney failure can eventually occur. It
is a trending health concern in the nursing profession because if AGN is not
treated then it will progress to kidney failure.
http://www.articlesbase.com/diseases-and-conditions-articles/a-serious-kidney-
problem-kidney-infections-and-their-causes-2872529.html#ixzz1Bpbx7gyj . As
nurses our responsibility is to prevent the progression of the symptoms.

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BACKGROUND OF THE STUDY

Alternative Names: Glomerulonephritis - acute; Acute

glomerulonephritis; Nephritis syndrome – acute. History: Bright initially
described acute glomerulonephritis (GN) in 1927. Acute poststreptococcal
glomerulonephritis (PSGN) is the archetype of acute GN. Acute nephritic
syndrome is the most serious and potentially devastating form of various renal
syndromes. Acute GN is characterized by the abrupt onset
of hematuria and proteinuria, often accompanied by azotemia (ie,
decreased glomerular filtration rate [GFR]) and renal salt and water
retention. http://emedicine.medscape.com/article/239278-overview
http://www.umm.edu/ency/article/000495.htm/

Acute glomerulonephritis refers to a specific set of renal diseases in which

an immunologic mechanism triggers inflammation and proliferation of glomerular
tissue that can result in damage to the basement membrane, mesangium, or
capillary endothelium. Hippocrates originally described the manifestation of back
pain and hematuria, which lead to oliguria or anuria. With the development of the
microscope, Langhans was later able to describe these
pathophysiologic glomerular changes. Most original research focuses on the
poststreptococcal patient. Acute glomerulonephritis is defined as the sudden
onset of hematuria, proteinuria, and red blood cell casts. This clinical picture is
often accompanied by hypertension, edema, and impaired renal function. As will
be discussed, acute glomerulonephritis can be due to a primary renal or systemic
disease. In acute glomerulonephritis, the kidneys are normal in size or enlarged
and edematous, and the surface of the kidney may show punctate hemorrhages.
http://emedicine.medscape.com/article/239278-overview

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 Glomerulonephritis represents 10-15% of glomerular diseases. Variable
incidence has been reported due in part to the subclinical nature of the disease in
more than one half the affected population. Despite sporadic outbreaks,
incidence of poststreptococcal glomerulonephritis has fallen over the last few
decades. Most cases occur in patients aged 5-15 years. Only 10% occur in
patients older than 40 years. http://emedicine.medscape.com/article/239278-
overview. In the Philippines, there are 2,346,281 who had AGN as of 2010. The
survival rate varies, however. For instance, it is lower for people with diabetes
than those with glomerulonephritis, a disease that causes inflammation of the
glomeruli in the kidneys, leading to kidney damage. In many cases, a transplant
is preferred to dialysis and may triple life expectancy after kidney failure.
http://ezinearticles.com/?Kidney-Disease-Prevalence---A-World-
Epidemic&id=5030568.

Causes: Glomerulonephritis can be caused by various disorders, such

as infections, an inherited genetic disorder, or autoimmune disorders:
Streptococcal infection of the throat (strep throat) or skin (impetigo), Hereditary
diseases, Immune diseases, such as lupus, Type 1 diabetes and Type 2
diabetes, High blood pressure, vasculitis (inflammation of the blood vessels),
viruses–human immunodeficiency virus (HIV), hepatitis B virus, and hepatitis C
virus and endocarditis (infection of the valves of the heart). Glomerulonephritis
can be primary, affecting only the kidneys, or secondary, caused by a vast array
of disorders that affect other parts of the body. Acute glomerulonephritis most
often occurs as a complication of throat or skin infection by streptococcus,
a type of bacteria. Acute glomerulonephritis that occurs after a streptococcal
infection (post-streptococcal glomerulonephritis) typically develops in children
between the ages of 2 and 10 following recovery from the infection. Infections
with other types of bacteria, such as staphylococcus and pneumococcus, viral
infections, such as chickenpox, and parasitic infections, such as malaria, can
also result in acute

5
glomerulonephritis.http://www.merckmanuals.com/home/sec11/ch144/ch144b.ht
ml. There are two forms of acute glomerulonephritis: postinfectious
glomerulonephritis and infectious glomerulonephritis. Postinfectious
glomerulonephritis typically occurs about 21 days after a respiratory or
skin infection with Streptococcus. Infectious glomerulonephritis occurs during or
within a few days of streptococcal infection. The disease may result in high blood
pressure (hypertension), fluid accumulation (edema), and kidney failure. Of the
two types, postinfectious glomerulonephritis (also called acute poststreptococcal
glomerulonephritis) is the most common.
http://www.mdguidelines.com/glomerulonephritis-acute

Risk factors for glomerulonephritis include: Family history of

glomerulonephritis and the presence of a known cause of glomerulonephritis.
http://www.mdguidelines.com/glomerulonephritis-acute. The most common risk
factor for development of postinfectious glomerulonephritis is an untreated
streptococcal infection of the respiratory tract and, less commonly, of the
skin. Males are twice as likely to have the condition as females, and although
glomerulonephritis can appear at any age, 90% of cases occur in those under 40
years. The disease most often develops in boys between 2 and 14 years (Kazzi).

Diagnostic tests includes: Blood tests, these can provide information

about kidney damage and impairment of the filtering mechanisms by measuring
levels of waste products, such as creatinine and blood urea nitrogen. Imaging
tests, if your doctor detects evidence of damage, he or she may recommend
diagnostic studies that allow visualization of your kidneys, such as a kidney X-
ray, an ultrasound examination or a computerized tomography (CT) scan.
Kidney biopsy, this procedure involves using a special needle to extract small
pieces of kidney tissue for microscopic examination to help determine the cause
of the inflammation. A kidney biopsy is almost always necessary to confirm
a diagnosis of glomerulonephritis. Urinalysis, a test to look for blood, protein,

6
bacteria, and other evidence of kidney damage in the urine. Ultrasound , a test
that uses sound waves to create images of the kidneys. Abdominal CT scan , a
type of x-ray test that uses a computer to create detailed images of the structures
inside the abdomen, including the kidneys.
http://www.mayoclinic.com/health/glomerulonephritis/DS00503/DSECTION=tests
-and-
diagnosis/http://www.aurorahealthcare.org/yourhealth/healthgate/getcontent.asp
?URLhealthgate=%2296731.html%22

Signs and symptoms of glomerulonephritis may depend on whether you

have the acute or chronic form, and the cause. Your first indication that
something is wrong may come from symptoms or from the results of a routine
urinalysis. Signs and symptoms may include: Cola-colored or diluted, iced-tea-
colored urine from red blood cells in your urine (hematuria), Foamy urine due to
excess protein (proteinuria), High blood pressure (hypertension), Fluid retention
(edema) with swelling evident in your face, hands, feet and abdomen, Fatigue
from anemia or kidney failure, Less frequent urination than usual. About half of
the people with acute glomerulonephritis have no symptoms. If symptoms
do occur, the first to appear are tissue swelling (edema) due to fluid retention,
low urine volume, and production of urine that is dark because it contains
blood. Edema may first appear as puffiness of the face and eyelids but later is
prominent in the legs. Blood pressure increases as kidney function becomes
impaired. In turn, high blood pressure and swelling of the brain may produce
headaches, visual disturbances, and more serious disturbances of brain function
(for example, seizures or coma). In older people, nonspecific symptoms, such as
nausea and a general feeling of illness (malaise), are more common.
When rapidly progressive glomerulonephritis develops, weakness, fatigue,
and fever are the most frequent early symptoms. Loss of appetite, nausea,
vomiting, abdominal pain, and joint pain are also common. About 50% of people
have a flu-like illness in the month before kidney failure develops. These people

7
have edema and usually produce very little urine. High blood pressure is
uncommon and rarely severe when it does occur.
http://www.merckmanuals.com/home/sec11/ch144/ch144b.html/http://www.mayo
clinic.com/health/glomerulonephritis/DS00503/DSECTION=symptoms

Medical Management: The goal of treatment is to reduce the

inflammation. You may need to stay in a hospital to have acute nephritic
syndrome diagnosed and treated. The cause must be identified and treated.
Treatment may include antibiotics or other medications or therapies.Your
doctor may recommend bedrest. You may need to limit salt, fluids, and
potassium in your diet. Your health care provider may prescribe medications to
control high blood pressure. Corticosteroids or other anti-inflammatory
medications may be used to reduce inflammation. Temporary dialysis is the
therapeutic procedure that helps in removal of excess fluids and thus controls
high blood pressure. This is mainly performed for acute glomerulonephritis and
acute kidney failure.Kidney transplantation and kidney dialysis are the
therapeutic procedures provided for chronicglomerulonephritis. Transplantation
is not always possible as it involves risks hence dialysis is the only best
option.http://healthtools.aarp.org/adamcontent/acute-nephritic-syndrome/3 /
http://www.ygoy.com/index.php/glomerulonephritis-%E2%80%93-treatment-
prevention-and-home-remedies-for-glomerulonephritis/

 Nursing Management:  Review fluid and diet restrictions. Measure

and record intake and output. Instruct patient to schedule follow-up evaluations
of blood pressure, urinalysis for protein, and BUN and creatinine studies to
determine if disease has worsened. Instruct patient to notify physician if
infection or symptoms of renal failure occur: fatigue, nausea, vomiting,
diminishing urinary output. Refer to home care nurse as indicated for
assessment and detection of early symptoms and follow-up evaluations.
Promote renal function: Strictly measure and monitor intake and output and

8
 maintain dietary restrictions. Encourage rest to facilitate diuresis and until renal
function test levels normalize.Administer medications as ordered and evaluate
effectiveness of treatment.Improve fluid balance: Carefully monitor fluid
balance and and replace fluids according to patient’s fluid losses. Get daily
weight.Monitor for signs and symptoms of heart failure and hypertensive
encephalopathy.http://faculty.ksu.edu.sa/73577/Pages/Acuteglomerulonephritis
.aspx/http://nursingcrib.com/nursing-notes-reviewer/medical-surgical-
nursing/glomerulonephritis/

Prevention: Control your blood pressure levels. This decreases the

likelihood of kidney damage caused from high blood pressure.Control your blood
sugar. This reduces the risk of diabetic nephropathy.Avoid intravenous drug
usage and follow safe sex guidelines. This helps to prevent infections such as
hepatitis and HIV that may lead to glomerulonephritis. Seek an immediate
treatment if you are infected with streptococcus that causes impetigo or sore
throat. Seek prompt treatment of a strep infection causing a sore throat or
impetigo.To prevent infections, such as HIV and hepatitis, that can lead to some
forms of glomerulonephritis, follow safe-sex guidelines and avoid intravenous
drug use.Control your blood sugar to help prevent diabetic nephropathy.Control
your blood pressure, which lessens the likelihood of damage to your kidneys
from hypertension. http://www.ygoy.com/index.php/glomerulonephritis-
%E2%80%93-treatment-prevention-and-home-remedies-for-glomerulonephritis/

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 Chapter II

Review of Related Literature

What is Acute Glomerulomephritis?

“Research results from University of Verona update understanding of

glomerulonephritis”
http://www.highbeam.com/doc/1G1-226879352.html
The majority of children with the epidemic form of acute post-
streptococcal glomerulonephritis(APSGN) have an excellent prognosis, which
contrasts with the poor long-term outcome of sporadic cases. Therapy is largely
supportive," scientists in Verona, Italy report (see also Glomerulonephritis).
"Rarely, the disease shows long-term complications, worsening to chronic kidney
disease requiring long-term interventional measures. To compare the effective
effectiveness of different therapeutic strategies for the prevention and treatment
of APSGN in childhood, the authors reviewed randomized controlled trials on the
prevention and treatment of APSGN in children . 

Acute Glomerulonephritis can lead to Kidney failure

“Nephrology: New Insight Into Common Kidney Disease”

http://www.sciencedaily.com/releases/2010/04/100419233256.htm

New research in mice, performed by Alan Salama and colleagues, at

Hammersmith Hospital, United Kingdom, has identified a potential new drug
target for the treatment of crescentic glomerulonephritis. In the study, mice
lacking the mannose receptor protein were found to be protected from crescentic
glomerulonephritis. This protection was associated with decreased kidney
damage mediated by cells known as macrophages and mesangial cells. Further,
macrophages lacking the mannose receptor actually became antiinflammatory in

10
the kidney after they interacted with mesangial cells. The authors therefore
suggest that targeting the mannose receptor might provide a new approach to
treating crescentic glomerulonephritis. Importantly, this approach would not have
the wide-ranging immunosuppressive effects that many current therapies have.

Diagnosis for Acute Glomerulonephritis

“The diagnosis of glomerular diseases: acute glomerulonephritis and

the nephrotic syndrome.”
http://www.ncbi.nlm.nih.gov/pubmed/11146695

Rapid and efficient diagnosis of diseases presenting as acute

glomerulonephritis and/or nephrotic syndrome is critical for early and appropriate
therapy aimed at preservation of renal function. Although there may be overlap in
clinical presentation, and some patients present with clinical features of both
syndromes, this analysis serves as an initial framework to proceed with serologic
testing and/or pathologic confirmation en route to final diagnosis. Efficient and
timely diagnosis is essential in these situations because progression to end-
stage renal disease may result if the underlying disease is not promptly treated.

Kidney Transplant for Kidney Disease

“Earlier Not Necessarily Better When Receiving A Kidney Transplant”

http://www.sciencedaily.com/releases/2009/10/091029211523.htm
Kidney disease patients with pre-dialysis transplants ("preemptive"
transplantation) tend to live longer and have higher functioning transplants than
post-dialysis transplant recipients. However, researchers didn't know if higher
kidney function among pre-dialysis recipients improves patients' long-term health.
To find out, Basit Javaid, MD (Stanford University School of Medicine), and his
colleagues analyzed data from the United Network for Organ Sharing (UNOS)
and looked at all preemptive kidney transplant recipients who received their first

11
kidney transplant between October, 1987 and February, 2009. These 25,748
preemptive kidney transplant recipients were divided into two groups: patients
with higher kidney function and patients with lower kidney function at the time of
transplant.The investigators found that patient and kidney transplant survival
were similar in the two groups. "Based on these findings, we feel that patients
and transplant experts anticipating a preemptive kidney transplant can wait for
clinical indications to emerge without any significant loss of survival advantage
associated with a preemptive transplant," said Dr. Javaid. The researchers did
note, however, that patients with higher kidney function needed less dialysis
within the first week after transplantation and were less often treated for kidney
rejection in the first six months after transplantation.

Medical Treatment for AGN

“Popular Heart Drug May Be Unsafe for Some Kidney Patients”

http://www.sciencedaily.com/releases/2010/06/100624183009.htm

The researchers monitored more than 120,000 dialysis patients drawn

from over 1,800 clinics across North America for up to four years. "We were
surprised to find that digoxin use increased death risk in dialysis patients,
especially in patients on higher doses," comments Kevin Chan, MD, MSci,
Fresenius Medical Care North America, Waltham, MA. The new and national
study raises concern that digoxin could in fact be dangerous when used in kidney
disease patients on dialysis. However, Dr. Chan emphasizes that since the study
was based on clinical surveillance data, the findings cannot be considered
conclusive. "Further research is needed to outline how and if digoxin can be
safely prescribed in patients on hemodialysis," he says.
In the meantime, Dr. Chan encourages doctors, patients, and healthcare
providers to reconsider the benefits of digoxin when alternative treatments are
available for heart disease in patients starting dialysis. He adds, "For patients

12
who remain on digoxin, vigilant monitoring of digoxin and potassium blood levels
can minimize the drug's possible side effects."

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 Chapter III

Client Presentation

PATIENT PROFILE

Name:
Age:
Birthday:
Address:
Nationality:
Civil Status: Single
Religion: Roman Catholic
Admission:
Chief Complaint:
Admitting Physician: Dr. R. Espinoza
Hospital: St. Luke’s Medical Center
Ward: Private Room
Admitting Diagnosis:
Weight upon admission:
Height:
Blood type:
Blood Pressure upon admission:

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