Question

Application to Practice Scenario

A 13-year-old boy presented to the clinic complaining of a sore throat that persisted for 2 days. After those 2 days, he developed fever, nausea, and malaise. A throat culture revealed the presence of Group A beta hemolytic streptococci, and the child was started on antibiotic therapy. The child’s symptoms gradually improved, but approximately 2 weeks later, he returned to the clinic because the fever, nausea, and malaise returned. He became tachypneic and short of breath.

The mother noted that his eyes were puffy, his ankles were swollen, and his urine was dark and cloudy. On examination, the child’s blood pressure was 148/100 mm Hg, his pulse was 122 beats/min, and his respirations were 35/min. Orbital and ankle edema were present. Rales (abnormal breath sounds) were auscultated bilaterally in the chest, but no heart murmurs were found. Slight tenderness to percussion over the flank areas was noted.

A chest X-ray showed evidence of congestion and edema in the lungs.

The patient’s hematocrit was 37% and his WBC was 11,200/mm3. Blood urea nitrogen was 48 mg/dL (normal is less than 20 mg/dL). Urinalysis results showed that the patient’s protein was 2+ (24-hour excretion was 0.8 g), specific gravity was 1.012, and there were moderate amounts of RBCs and WBCs in the urine. Serum albumin was 4.1 g/dL (normal is 3.5–4.5).

1.Which evidence supports the conclusion that this patient has a kidney disease?

2.Which clinical pattern of kidney disease does this patient have? Can you explain the symptoms?

3.Which morphologic changes would you expect in the kidney?

4.What is the prognosis? What are the possible short- and long-term complications of this disease? Is it necessary to hospitalize the patient?

Answer 1

Answer 1) The evidnce that supports the presence of kidney disease- Puffy eyes, ankle oedema, increased blood pressure, cloudy dark urine, presence of proteinuria (protein in urine), increased BUN, RBC and WBC in urine

Answer 2) The child has clinical picture of nephrotic syndrome

Clinical features of nephrotic syndrome are edema, proteinuria, lipiduria, albuminuria, pleural effusion, increased blood pressure, hyperlipidaemia.

Answer 3) Morphologic changes in kidney:-

Crescent formation in the glomerulus. it consists of parietal epithelial cells of Bowman's capsule with presence of macrophages, neutrophils, lymphocytes, fibrin and collagen.

Answer 4) Complications of glomerulonephritis

Thromboembolic phenomenon

Acute kidney injury due to hypovolemia

Hypotension

Pulmonary edema

Growth retardation

Malnutrition - due to loss of protien in urine

If treated early with corticosteroids, cyclophophamide the disease has good prognosis.

Hospitalisation is required in cases of gross edema as it can compromise the respiratory tract and may result in hypoxia. Also, it can result in hypovolemia and hypotension.