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  • Edema, hematuria, and oliguria suggest acute glomerulonephritis.
  • Children with nephrotic syndrome are usually immunocompromised and at risk for life-threatening infection.
  • Patients with hemolytic uremic syndrome are at risk for hypertension and seizures.
  • Hemodialysis may be needed for fluid overload in patients with acute renal failure who are refractory to medical management.

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Glomerulonephritis is a histopathologic diagnosis acutely associated with clinical findings of hematuria, edema, and hypertension. It commonly follows a pharyngitis caused by group A β-hemolytic Streptococcus in children between 3 and 7 years of age. Patients < 2 years are rarely affected. Timely treatment of pharyngitis does not clearly decrease the incidence of acute glomerulonephritis.

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Glomerulonephritis probably results from the deposition of circulating immune complexes in the kidney. These immune complexes are deposited on the basement membrane, reducing glomerular filtration.1

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Diagnostic Findings

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There is usually a preceding streptococcal infection or exposure 1 to 2 weeks before the onset of glomerulonephritis. An interval of less than 4 days may imply that the illness is an exacerbation of preexisting disease rather than an initial attack. Fever, malaise, abdominal pain, and decreased urine output are often noted.

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The physical findings reflect the duration of illness. Initial findings may be mild facial or extremity edema only, with a minimal rise in blood pressure. Patients uniformly develop fluid retention and edema and commonly have hematuria (90%), hypertension (60%–70%), and oliguria (80%). Fever, malaise, and abdominal pain are frequently reported. Anuria and renal failure occur in 2% of children. Circulatory congestion, as well as hypertensive encephalopathy, may be noted.

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Ancillary Data

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Urinalysis reveals microscopic or gross hematuria. Erythrocyte casts are present in 60% to 85% of hospitalized children. Proteinuria is generally less than 2 g/m2 per 24 hours. Hematuria (Fig. 84–1) and proteinuria (Fig. 84–2) may present independently and require a specific evaluation.2 Leukocyturia and hyaline and granular casts are common.

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Figure 84-1.
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Evaluation for hematuria. TB, tuberculosis; RBC, red blood cell; BUN, blood urea nitrogen; Ca, calcium; Cr, creatinine; ANA, antinuclear antibody. (With permission from Barkin RM, Rosen P, eds. Emergency Pediatrics: A Guide to Ambulatory Care. 6th ed. St. Louis, MO: Mosby; 2003:269.)

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Figure 84-2.
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Evaluation for proteinuria. BUN, blood urea nitrogen. (With permission from Barkin RM, Rosen P, eds. Emergency Pediatrics: A Guide to Ambulatory Care. 6th ed. St. Louis, MO: Mosby; 2003:269.)

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The fractional excretion of sodium as a reflection of renal function may be reduced (Table 84–1). The blood urea nitrogen (BUN) level is elevated disproportionately to the creatinine level.

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Table Graphic Jump Location
Table 84-1. Evaluation of Renal Failure

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