A 3-year-old child had a fever and swollen eyelids for 4 days, accompanied by blood routine and urine routine.

3. Tests still need to be done, including microscopic examination of urine red blood cells in occult blood, examination of streptococcus antibody (because it is acute, it may be negative), and renal color ultrasound.

3. Antibiotics are needed for treatment, and penicillin is recommended.

4. Eat a low-salt and low-protein diet and stay in bed.

It is best to be hospitalized.

Related information:

Acute glomerulonephritis is often called acute glomerulonephritis. Broadly speaking, it refers to a group of glomerular diseases with different etiology and pathogenesis, but the clinical manifestations are acute onset, characterized by hematuria, proteinuria, edema, hypertension and decreased glomerular filtration rate, so it is often called acute nephrotic syndrome. Clinically, it is mostly glomerulonephritis after acute streptococcal infection. This disease is the most common kidney disease in childhood. 3 ~ 8 years old is more common, but less common under 2 years old. The ratio of male to female is about 2: 1.

diagnose

Typical acute nephritis is not difficult to diagnose. After streptococcal infection, after an asymptomatic interval of 1 ~ 3 weeks, edema, hypertension and hematuria (which may be accompanied by different degrees of proteinuria) appear, and then the diagnosis can be made by the dynamic changes of blood complement C3. 1. Before onset 1 ~ 4 weeks, he had a history of streptococcus infection such as upper respiratory tract infection, tonsillitis, scarlet fever or skin suppuration. 2. edema. 3. Oliguria and hematuria. 4. High blood pressure. 5. In severe cases, the following complications may occur: ① circulatory congestion and heart failure; ② Hypertensive encephalopathy; ③ Acute renal failure. 6. Laboratory examination ① The urine routine is mainly red blood cells, and there may be light or moderate protein or granular casts. ② Blood urea nitrogen can temporarily increase when oliguria occurs. ③ Erythrocyte sedimentation rate increased rapidly in acute phase. The anti-"O" titer increased, mostly above 1: 400. ④ The determination of serum complement C3 decreased obviously after 2 weeks of onset, and 1 ~ 2 months returned to normal.

diagnostic criteria

1, the kidney is swollen, and the diameter of the kidney is increased, especially the thick diameter, which makes the kidney bulge, plump and spherical. 2. The renal capsule is not clearly displayed, and the contour boundary is unclear and the edge is blurred. 3. The renal parenchyma is thickened, the echo is diffused and strengthened, the light spot is blurred and covered like a cloud, there is no difference between renal cortex and renal medulla, and the echo of renal sinus is relatively faded, even the whole section is complete, which can not show the normal renal structure. 4. Different pathological changes of acute glomerulonephritis, although different, make the sonographic manifestations different, such as appearance, capsule blur, renal cortex and medulla clarity, renal sinus echo and so on. But the overall characteristics of inflammatory lesions are consistent. [ 1]

Treatment measures

At present, scientists are directly targeting the specific treatment of glomerular immunopathology. Mainly through symptomatic treatment to correct its pathophysiological process (such as water and sodium retention tumor, hypervolemia), prevent and treat acute complications, protect renal function and promote its natural recovery. 1. In the acute stage, people usually stay in bed for 2-3 weeks. After gross hematuria disappears, blood pressure recovers and edema is relieved, indoor activities can be gradually increased. Follow-up observation should be strengthened for the remaining mild proteinuria and hematuria, and bed rest time should not be prolonged. If urine volume changes and weight increases, you need to stay in bed again. Avoid strenuous physical activity for three months. After you stop lying in bed, you can gradually increase your activity. If there are no clinical symptoms, the urine is basically normal after 2 months, and you can start school for half a day and gradually participate in full-time study. 2. Diet and Intake In order to prevent further water and sodium retention and lead to serious circulatory overload, it is necessary to reduce the burden on the kidneys, and limit the intake of salt, water and protein in the acute stage. For people with edema and hypertension, use a salt-free or low-salt diet. Those with severe edema and less urine are limited to water. Limit protein intake in patients with azotemia. The application of high-quality protein for children in a short time can be calculated as 0.5g/kg. Pay attention to providing heat with sugar and so on. 3. Treatment of infected lesions If there are still infected lesions of throat and skin, penicillin or other sensitive drugs should be used for 7 ~ 10 days. 4. The application of diuretics in acute nephritis, the main pathophysiological changes are water and sodium retention and the expansion of extracellular fluid, so the application of diuretics not only achieves the effect of diuresis and detumescence, but also helps to prevent and treat complications. Those who still have less urine, edema and high blood pressure after controlling water and salt should be given diuretics. When thiazide drugs are ineffective, powerful diuretics such as furosemide and uric acid can be used. Mercury diuretics are generally prohibited. 5. antihypertensive drugs should be given to those who have been resting, limiting water and salt, diuresis and still have high blood pressure. Reserpine is still commonly used in pediatrics. The first dose can be 0.07mg/kg orally or intramuscularly (the maximum dose is no more than 2mg each time), and it can be repeated at 12 hours if necessary. After the first dose, it is generally taken orally, calculated at 0.02 ~ 0.03 mg/kg per day, and taken orally for 2 ~ 3 times. The side effects are nasal congestion, fatigue, conjunctival congestion, redness and bradycardia. Repeated injection or combination with chlorpromazine should be avoided, because Parkinson-like symptoms may occasionally occur, such as unclear pronunciation, involuntary tremor and increased muscle tone. Hydrazine, 0. 1 mg/kg ~ intramuscular injection or 0.5mg/kg(kg? D) The main side effects are headache, increased heart rate and gastrointestinal irritation. In recent years, calcium channel blockers, such as nifedipine, are commonly used when blood pressure rises significantly. After 20 minutes, blood pressure began to drop, and the effect of 1 ~ 2 hours reached its peak, lasting for 6 ~ 8 hours, or using angiotensin converting enzyme inhibitors, such as captopril. Patients with hypertensive encephalopathy who need urgent blood pressure reduction can choose the following intravenous drugs: sodium nitroprusside, especially suitable for pulmonary edema. This medicine takes effect quickly, and it takes effect after 10 seconds. But the maintenance time is short. The effect disappears after stopping using for 3 ~ 5 minutes, and the static point must be maintained. Children can be given 5 ~ 20 mg, dissolved in 100ml glucose solution, and the dose is 1μg(kg? Min) speed, adjust the number of drops according to blood pressure. Pay attention to the dripping speed, fresh preparation, and the infusion bottle should be wrapped in black paper to avoid light. Another rapid intravenous antihypertensive drug, diazoxide, has the function of directly dilating blood vessels. The dosage is 3 ~ 5 mg/kg, which can be injected intravenously quickly. When the effect is not ideal, it can be repeated after 30 ~ 60 minutes. The maximum antihypertensive effect can be achieved in 5 minutes after use and maintained for 8 hours. The side effects were occasional malignant tumor, headache, palpitation and transient ventricular arrhythmia. It is considered that magnesium sulfate is a commonly used antihypertensive drug, but it has been rarely used in recent years because of other effective drugs and the risk of magnesium poisoning caused by renal insufficiency. 6. Treatment of acute complications (1) Treatment of acute circulatory congestion: This disease is mainly caused by water and sodium retention and blood volume expansion, so the treatment of this disease should focus on correcting water and sodium retention and restoring blood volume, rather than strengthening myocardial contractility with digitalis. In addition to diuretics, phentolamine or sodium nitroprusside should be added when necessary to reduce the load before and after the heart. Peritoneal dialysis is feasible for patients who can't be controlled after the above treatment, so as to quickly relieve the overload of circulation. (2) Treatment of hypertensive encephalopathy: Besides strong and effective antihypertensive drugs to control blood pressure, we should also pay attention to symptomatic treatment. Diazepam 0.3mg/(kg? Time), the total amount does not exceed 20 mg, intravenous injection, or other antispasmodic drugs. Diuretics help to lower blood pressure, and this disease is often accompanied by brain edema, so it is advisable to use quick-acting and powerful diuretics. (3) Acute renal failure: See relevant chapters. 7. Other treatments generally do not use adrenocortical hormone. Dialysis can be used to treat severe oliguria or anuria, high circulatory congestion and uncontrollable hypertension that are ineffective in drug treatment. 8. Chinese medicine treatment Chinese medicine believes that acute nephritis is caused by the invasion of wind evil, damp heat and sore poison, which affects the gasification function of lung, spleen and kidney. Therefore, in the acute stage, eliminating pathogenic factors is the main treatment, and eliminating dampness is the main treatment. Can be used for ephedra forsythia 9g, adzuki bean 30g, Poria cocos peel 15g, Alisma orientalis 10g, and wax gourd peel 15 ~ 30g. (2) Hua Shuang 10g and dandelion10g were added to the toxic heat; ③ 15g； Edema urine plus plantain seed; ④ Hematuria: Cirsium japonicum increased by 65,438 00 g, and Radix Rehmanniae increased by 65,438 00 g; ⑤ For patients with hypertension, concha Haliotidis 15 ~ 30g, Scutellaria baicalensis Georgi 10g and Chrysanthemum morifolium 10g are added. When there is only slight urine abnormality in the recovery period, it can be treated to regulate the spleen and kidney and clean up the remaining pathogens. Jianpi decoction is often used to add and subtract. Examples of prescriptions are: Poria cocos 10g, Dioscorea opposita 10g, Zhengzhenzi 10g, Platycladus orientalis 10g, Zaolian 10g, and medulla tetrapanacis 3g.

Syndrome Differentiation and Treatment of Acute Nephritis

According to different causes and symptoms, acute nephritis adopts different treatment prescriptions. 1. Feng Shui fight? Symptoms: Eyelid swelling first, then limbs, even chest and abdomen, bright skin, short and yellow urine, hematuria, fever, cough, pain in limbs, sore throat, thin and white fur and floating pulse. ? This syndrome is characterized by eyelid edema, bright skin, no depression, fever, bad wind, thin white fur and floating pulse. ? Treat diseases, dispel wind and benefit water. ? Prescription: Herba Ephedrae, Fructus Forsythiae and Semen Phaseoli Soup. Or more maids and soup? In the prescription, ephedra spreads the lung to dispel evil spirits, forsythia clears heat and detoxifies, and adzuki bean promotes diuresis to reduce swelling. ? If there is exterior cold, add Schizonepeta, Saposhnikovia divaricata and Notopterygium root to dispel wind and relieve exterior cold? If you feel cold in summer, you can add Elsholtzia and duckweed to relieve symptoms. Can you swim? For those who are fidgety and thirsty and have internal heat, Gypsum Fibrosum and Scutellaria baicalensis Georgi are added to clear the lung and prevent heat; ? If hematuria is obvious, imperata rhizome and Cirsium japonicum are added to clear away heat and stop bleeding; ? For throat moth, Achyranthes bidentata, Lasiopogon japonicus and Radix Isatidis are added to detoxify and relieve sore throat; Or add or subtract with burdock orange soup. ? Dampness is better than wind, and Pericarpium Arecae, Poria, Polyporus and Alisma orientalis are added to promote diuresis and eliminate dampness. ? 2. Hot and humid invasion? The symptoms are edema, short and red urine, hematuria, sore poison, red tongue, thin yellow fur and slippery pulse. ? The syndrome is characterized by short and red urine, skin sores and red tongue with yellow fur. ? Treat heat and detoxify, lightly permeate and promote diuresis. ? Prescription Wuwei Disinfection Drink Combined with Wupi Drink? In the prescription, Flos Lonicerae, Flos Chrysanthemi Indici, Herba Violae, Semen semiaquilegiae and Herba Taraxaci can clear away heat and toxic materials, while Pericarpium Citri Reticulatae, Cortex Mori, Cortex Zingiberis Recens, Pericarpium Arecae and Cortex Acanthopanacis have low permeability and diuretic effect. ? If the swelling is serious, plantain and talc are added to induce diuresis to reduce swelling; ? For patients with skin sores, Radix Sophorae Flavescentis and Cortex Dictamni Radicis are added to facilitate dampness and detoxification; ? For those with obvious hematuria, increase the blood of Cirsium japonicum, Cirsium japonicum, Pyrrosia pyrrosia, Cortex Moutan, Radix Rehmanniae and Lalang Grass Rhizome to stop bleeding. ? Dampness and heat: edema, thirst, yellow and greasy fur, and heavy pulse. You can drink it with a fine chisel: [next page]? 3. Deficiency of lung and spleen? The syndrome is cured or the course of disease is longer. It can be manifested as no or no edema, pale face, fatigue, easy sweating, easy to catch a cold, pale tongue with white fur, and slow and weak pulse. ? This syndrome is characterized by edema, sweating, cold, pale tongue and white fur. ? Treatment of spleen qi. ? Prescription Shen Ling Baizhu Powder and Yupingfeng Powder. ? Shen Ling Baizhu Powder strengthens the spleen and stomach and promotes diuresis, aiming at strengthening the soil and promoting diuresis, and consolidating the exterior with Astragalus membranaceus, Fangfeng Yiqi. ? If it persists for a long time, the kidney yin is insufficient, the tongue is red with little or no coating, and the pulse is thready, then the kidney yin should be treated, and Liuwei Dihuang Pill can be used. ? 4. Is the water vapor on the heart and lungs? Symptoms include oliguria or anuria, edema of limbs, cough and shortness of breath, palpitation and chest tightness, irritability, difficulty lying flat, and cyanosis of lips. Cyanosis of nails, white or greasy fur, weak pulse. ? This syndrome is characterized by edema of limbs, cough and shortness of breath, palpitation and chest tightness, blue lips and weak pulse. ? Treatment: purging lung and promoting diuresis, warming yang and strengthening body resistance. ? Prescriptions include Jiaojuanhuang Pill and Shenfu Decoction. ? In the prescription, prickly heat and rhubarb can drain the lungs, pepper the eyes, protect the body and benefit the water, and ginseng can greatly replenish the vitality, which is strong in moderate temperature. ? Cinnamon, Os Draconis and Concha Ostreae are added for patients with limb syncope and hyperhidrosis, so as to warm yang and stop sweating; For those with short urine, cassia twig and Alisma orientalis are added to warm channels and promote diuresis. [Next Page]? 5. evil is trapped in the heart? Symptoms include headache, dizziness, blurred vision, irritability, even convulsions and coma, red tongue, yellow and rough fur and thready pulse. ? This syndrome is characterized by headache, dizziness, yellow fur and thready pulse. ? Purging fire and promoting diuresis, calming liver and suppressing yang. ? Self-made Longdan Xiegan Decoction and Jiao Ling Gouteng Decoction. ? Longdan Xiegan Decoction can clear excess heat in liver meridian, reuse Longdan to purge excess fire in liver meridian, combine antelope horn and Uncaria rhynchophylla to calm the liver and calm the wind, and assist Angelica sinensis, Radix Rehmanniae and Radix Paeoniae Alba to nourish blood and soften the liver, so that the liver fire can be purged and the liver wind can be extinguished, and then the spasm can be stopped. ? Add Pinellia ternata and Arisaema cum bile to vomit, and remove phlegm and turbidity; ? If you are unconscious, you can choose Angong Niuhuang Pill to clear away heat and begin to understand; ? For those who are frightened by wind, Uncaria and Concha Haliotidis should be added to stop wind and relieve spasm. ? 6. Water poisoning is closed internally? Symptoms include general edema, oliguria or anuria, dizziness, headache, nausea, vomiting and even coma, greasy tongue coating and thready pulse. ? The syndrome is characterized by oliguria or urinary incontinence, headache, nausea, greasy fur and thready pulse. ? Treat a bitter disease, remove filth and detoxify. ? Self-made Wendan decoction combined with Fuzi Xiexin decoction. ? Wendan decoction is Erchen decoction with bamboo shavings, immature bitter orange and jujube; ? Fuzi Xiexin Decoction consists of Radix et Rhizoma Rhei, Rhizoma Coptidis, Scutellariae Radix and Radix Aconiti Lateralis. In the prescription, Radix et Rhizoma Rhei, Scutellariae Radix and Rhizoma Coptidis have the functions of clearing away dirt and toxic materials, clearing away heat and purging fire, Radix Aconiti Lateralis warming channels to help yang, Rhizoma Zingiberis pungent and warm, Pericarpium Citri Tangerinae and Rhizoma Pinelliae wet and turbid, and Caulis Bambusae and Fructus Aurantii Immaturus clearing gallbladder and stomach. ? For patients with obvious nausea and vomiting, Yushu Dan is added to enhance the detoxification effect; Antelope horn powder and Zixuedan should be added for spasticity.

etiology

According to epidemiological, immunological and clinical studies, it is proved that this disease is immune complex glomerulonephritis caused by infection of β hemolytic streptococcus group A, and the basis is as follows: ① Before the onset of nephritis, there was streptococcus precursor infection; ② There is no evidence that Streptococcus directly invades the kidney; ③ There is an interval from streptococcal infection to nephritis, which is equivalent to the time required for antibody formation; ④ Antibodies and immune complexes against streptococcus and its products can be detected in patients' blood; ⑤ The complement component in blood is decreased; ⑥ IgG and complement components are deposited on glomerular basement membrane. Among group A β hemolytic streptococci, 12 is the main strain causing nephritis due to respiratory infection, and a few strains are 1, 3, 4, 6, 26, 49, and the invasion rate of nephritis is about 5%. The nephritis caused by skin infection is mainly type 49, and there are a few types 2, 55, 57 and 60, and the invasion rate can reach 25%.

pathogenesis

As for the mechanism of nephritis caused by infection, it is generally believed that the body produces antibodies to some antigenic components of streptococcus (such as M protein in cell wall or some antigenic components in cytoplasm), forming circulating immune complex, which reaches the kidney with blood flow. It deposits on glomerular basement membrane, and then activates complement, causing local immunopathological damage of glomerulus and causing diseases. But other mechanisms have been proposed in recent years. Some people think that some cationic antigens in streptococcus are first implanted into glomerular basement membrane and cause disease through in-situ complexes. Some people think that after infection, the normal IgG in the body changes under the action of enzymes, which makes it antigenicity and leads to the production of anti-IgG antibodies, that is, autoimmune mechanism also participates in the pathogenesis; Some people think that there is cross antigenicity between streptococcus antigen and glomerular basement membrane glycoprotein, and this few cases should belong to anti-renal antibody nephritis.

pathological change

Immune inflammation of glomerular capillaries narrows or even occludes the capillary lumen, damages the glomerular filtration membrane, and produces hematuria, proteinuria and tubular urine. And the glomerular filtration rate is reduced, so the excretion of water and various solutes (including nitrogen-containing metabolites and inorganic salts) is reduced, resulting in water and sodium retention, which in turn leads to an increase in extracellular fluid volume, so there are systemic circulation congestion such as edema, oliguria, dyspnea, hepatomegaly and increased venous pressure in clinic. At present, it is considered that the hypertension of this disease is caused by the increase of blood volume, and whether it is related to the enhanced activity of "Renin-Angiotensin-Aldosterone System" is still inconclusive.

clinical picture

The clinical manifestations of the disease vary greatly, and the mild one can be "subclinical", that is, there is no specific clinical manifestation except for abnormal laboratory examination; Severe cases are complicated with hypertensive encephalopathy, severe circulatory congestion and acute renal failure. 1. Precursor infections and intermittent precursor diseases are often upper respiratory tract infections caused by streptococcus, such as acute suppurative tonsillitis, pharyngitis, lymphadenitis and scarlet fever. Or skin infection including pustulosis and furuncle. There is an asymptomatic interval from precursor infection to getting to the point. Respiratory infection causes about 10 days (6 ~ 14 days), and skin infection causes about 20 days (14 ~ 28 days). 2. The clinical manifestations of typical cases are acute onset in asymptomatic interval 1 ~ 3 weeks after streptococcus precursor infection, with edema, hematuria, hypertension and renal function involvement in different degrees. Edema is the most common symptom, which is caused by decreased glomerular filtration rate and water and sodium retention. Generally, edema is not very serious. At first, it only involves eyelids and face. Lift it in the morning. Severe cases affect the whole body, and a few cases may be accompanied by pleural effusion and ascites; Lighter people just gain weight and feel full in their limbs. Acute nephritis edema is not depressed, which is different from nephrotic syndrome. Half of the sick children have gross hematuria; Microscopic hematuria can be found in almost all cases. When hematuria appears to the naked eye, the color of urine can be meat washing water sample, smoke gray, brownish red or bright red. The color difference of hematuria is related to the pH value of urine. Acid urine is grayish white or brownish red, neutral or alkaline urine is bright red or meat washing water sample. When gross hematuria is serious, it may be accompanied by dysuria or even dysuria. Usually gross hematuria turns into microscopic hematuria after 1 ~ 2 weeks, and a few of them last for 3 ~ 4 weeks. It can also be temporarily repeated due to infection and fatigue. Microscopic hematuria lasts for 1 ~ 3 months, a few last for more than half a year, but most of them can recover. Hematuria is often accompanied by different degrees of proteinuria, generally mild to moderate, and a few can reach the level of nephropathy. It is not uncommon for urine volume to decrease, but in fact only a few people have at least urine or no urine. Hypertension is found in 30% ~ 80% of cases, which is caused by water and sodium retention and blood volume expansion, and generally increases slightly or moderately. 1 ~ 2 weeks later, blood pressure dropped to normal, and diuresis was used to reduce swelling. If it does not continue to decline, the possibility of acute attack of chronic nephritis should be considered. At the same time of the above symptoms, children often have symptoms such as fatigue, nausea, vomiting and dizziness. Older children complain of dull pain in the waist, while younger children complain of abdominal pain. 3. There are the following typical cases in the morning: (1) asymptomatic subclinical cases, which can be completely free of edema, hypertension and gross hematuria. Only when streptococcal infection is prevalent, or when close contacts of children with acute nephritis have a routine urine examination, microscopic hematuria is found, and even the urine test is normal, but the complement C3 in the blood is reduced and recovered after 6-8 weeks. (2) The clinical manifestations are edema, hypertension, even severe circulatory congestion and hypertensive encephalopathy, but the routine urine examination changes slightly or normally, which is called "extrarenal symptomatic nephritis". The blood complement C3 of these children showed typical regular changes in the acute phase, and recovered in 6-8 weeks, which was helpful for diagnosis. (3) Urine protein and edema are serious, even similar to nephropathy, and some children may have plasma protein reduction and hyperlipidemia, which is not easy to distinguish from nephrotic syndrome.

complication

The main complications of acute phase The serious complications of acute phase mainly include severe circulatory congestion, hypertensive encephalopathy and acute renal failure. With the strengthening of prevention and control work in recent years, its morbidity and mortality have decreased significantly. 1. Circulating congestion: due to water and sodium retention, blood volume fails until pulmonary edema. Incidence is reported by different families, which is related to the severity and treatment of the disease. It is reported that 24% ~ 27% of hospitalized children with acute nephritis in China in 1950s and 1960s had this complication, which has decreased to 2.4% in recent years. Most of them occur within 1 ~ 2 weeks after the onset of acute nephritis. The clinical manifestations are shortness of breath, inability to lie down, chest tightness, cough, moist rales at the bottom of the lungs, great tenderness of the liver, rhythm and other symptoms of left and right heart failure, which are caused by the expansion of blood volume and are different from real myocardial pump failure. At this time, the cardiac output often increases, the circulation time is normal, the arterial and venous blood oxygen pressure difference does not increase, and the cardiotonic effect of digitalis is not good, so diuretics can often be used to relieve it. Very few severe cases can develop into real heart failure, and pulmonary edema will appear rapidly within a few hours to 1 ~ 2 days, which is life-threatening. 2. Hypertensive encephalopathy: refers to the sharp rise of blood pressure (especially diastolic blood pressure) and the appearance of central nervous system symptoms. Children are more common than adults. It is generally believed that this disease is caused by cerebral hypoxia and brain edema on the basis of systemic hypertension and vasospasm with small brain resistance; However, some people think that when blood pressure rises sharply, the automatic vasomotor function of cerebral blood vessels is out of control, and the cerebral blood vessels are highly congested, resulting in brain edema. In addition, water and sodium retention in acute nephritis also plays a role in the pathogenesis. It usually occurs in the early stage of acute nephritis, and the onset is generally urgent, characterized by severe headache, frequent nausea and vomiting, followed by visual impairment, dizziness, diplopia, temporary darkness, drowsiness or irritability. If not treated in time, convulsions, coma, a few temporary hemiplegia and aphasia will occur, and in severe cases, brain hernia will occur. The nervous system has no limited signs, shallow reflex and tendon reflex can be weakened or disappeared, ankle clonus is sometimes positive, and pathological reflex can also appear, and severe cases can have symptoms and signs of cerebral hernia. Retinal arteriolar spasm is common in fundus examination, and sometimes papillae edema can be seen. The cerebrospinal fluid is clear, and the pressure and protein are normal or slightly increased. If the blood pressure exceeds18.7/12.0 kpa (140/90 mmhg), it can be diagnosed as visual impairment, convulsion and coma. 3. Acute renal failure: A considerable number of children with acute nephritis have different degrees of azotemia in acute stage, but only a few of them progress to acute renal failure. Complications still lack effective preventive measures and have become the main cause of death in acute nephritis. The clinical manifestations are oliguria or anuria, blood urea nitrogen, elevated serum creatinine, hyperkalemia and metabolic acidosis. Oliguria or anuria lasts for 3 ~ 5 weeks or 1 week or more, then urine output increases, symptoms disappear, and renal function gradually recovers (see chapter "Acute Renal Failure" for details).

accessory examination

1. Urine test hematuria is an important manifestation of acute nephritis, either gross hematuria or microscopic hematuria. Most of the red blood cells in urine are severely deformed red blood cells, but they can be temporary non-renal deformed red blood cells when loop diuretics are used. In addition, the red blood cell cast can be seen, suggesting that there is hemorrhagic exudative inflammation in glomerulus, which is an important feature of acute nephritis. Urine sediment is also common in renal tubular epithelial cells, white blood cells and a large number of transparent and granular casts. Urine protein is usually (+) ~ (++), which is mostly non-selective. Fibrin degradation products (FDP) in urine increase. Urine routine generally returns to normal within 4 ~ 8 weeks. Residual microscopic hematuria (or abnormal Eddie count) or a small amount of proteinuria (which can be manifested as upright proteinuria) can last for half a year or longer. 2. Blood routine red blood cell count and hemoglobin can be slightly lower, which is caused by blood volume expansion and hemodilution. The white blood cell count can be normal or elevated, which is related to whether the primary infection focus continues to exist. The erythrocyte sedimentation rate increased rapidly and returned to normal within 2 ~ 3 months. 3. Blood chemistry and renal function tests showed that the glomerular filtration rate decreased to varying degrees, but the renal plasma flow was still normal, so the filtration fraction often decreased. Compared with glomerular function, renal tubular function is relatively good, and renal concentration function can be maintained. Transient azotemia is common in clinic, and blood urea nitrogen and creatinine are increased. Children who drink unlimited water may have mild diluted hyponatremia. In addition, sick children may have hyperkalemia and metabolic acidosis. Due to blood dilution, plasma protein can be slightly reduced. When proteinuria reaches the level of nephropathy, serum albumin drops obviously and may be accompanied by hyperlipidemia to a certain extent. 4. Cytological and serological examination: The positive rate of β hemolytic streptococcus cultured from throat or skin infection focus after acute nephritis is about 30%, and it is difficult to detect those who receive penicillin treatment in the early stage. Streptococcus infection can produce corresponding antibodies, which are often diagnosed by detecting antibodies. For example, the positive rate of anti-streptolysin O antibody (ASO) is 50% ~ 80%, which usually appears in 2 ~ 3 weeks after streptococcal infection, and the titer reaches the peak in 3 ~ 5 weeks, and 505 patients return to normal within half a year. When judging its clinical significance, it should be noted that the increase of its titer only indicates that there has been streptococcal infection recently, which is not directly related to the severity of acute nephritis. The positive rate of patients treated with effective antibiotics decreased, and the positive rate of patients with skin infection was also low. Anti-deoxyribonuclease B (B) and anti-hyaluronidase (anti-HAse) can still be detected and should be checked after 2 ~ 3 weeks. If the titer increases, it will be more diagnostic. 5. Determination of blood complement Except for a few cases, the total complement and C3 in the blood decreased obviously in the early stage of nephritis, and returned to normal after 6 ~ 8 weeks. This regular change is a typical manifestation of this disease. There is no obvious correlation between the decrease of blood complement and the mild symptoms of acute nephritis, but the low complement lasts for more than 8 weeks, so the possibility of other types of nephritis, such as membranous proliferative nephritis, cryoglobulinemia or lupus nephritis, should be considered. 6. Other tests: Circulating immune complex and cryoglobulin can be determined in acute phase in some cases. Usually, typical cases do not need renal biopsy, but it is difficult to distinguish them from acute nephritis. Or those who still have high blood pressure, low continuous exercise ability or impaired renal function 3 months after illness.

differential diagnosis

Renal diseases caused by different symptoms and various reasons can all manifest as acute nephritis syndrome, and sometimes they should be differentiated from the following patients: 1. It is known that glomerulonephritis infected by other pathogens can lead to nephritis and manifest as acute nephritis syndrome. Pathogens that can cause proliferative nephritis include bacteria (staphylococcus, pneumococcus, etc. ), viruses (influenza virus, EB virus, varicella virus, Coxsackie virus, adenoiditis virus, echovirus, cytomegalovirus inclusion virus and hepatitis B virus, etc. ), mycoplasma pneumoniae and protozoa. Referring to the medical history, the primary infection focus and its various characteristics can generally be distinguished. 2. Other primary glomerular diseases (1) membrane proliferative glomerulonephritis: The onset is similar to acute glomerulonephritis, but obvious proteinuria and persistent hypokalemia C3 often appear, and the course of disease is chronic, which can be distinguished. If necessary, a renal biopsy should be performed. (2) Acute glomerulonephritis: The onset is the same as that of acute glomerulonephritis, and the condition often worsens within 3 months. Hematuria, hypertension and acute renal failure with oliguria or anuria persist, and the mortality rate is high. (3)IgA nephropathy: Hematuria begins within 1 ~ 2 days after upper respiratory tract infection, usually without edema and hypertension. Generally, there is no decrease in complement, and sometimes there have been many hematuria attacks in the past. Renal biopsy is needed to determine the difficulty. (4) Primary nephrotic syndrome nephritis type: In the acute stage of nephritis, occasionally proteinuria reaches the level of nephropathy, which is easily confused with nephrotic syndrome. Through the analysis of medical history, complement detection and even the first-stage follow-up, it can be distinguished that renal biopsy is needed when it is difficult. 3. Systemic diseases or some hereditary diseases, such as lupus erythematosus, Henoch-Schonlein purpura, hemolytic uremic syndrome, polyarteritis nodosa, Goode-Pasture syndrome, Ahlport syndrome, etc. According to other manifestations of each disease, it can be distinguished. 4. Acute urinary tract infection or pyelonephritis can also manifest as hematuria in children, but most of them have symptoms of fever and urinary tract irritation. Urine is mainly white blood cells, which can distinguish positive urine bacterial culture. 5. Acute attack of chronic nephritis is easily mistaken for "acute nephritis", and the prognosis of the two is different, so it needs to be differentiated. This kind of children often have a history of kidney disease, and the attack is often induced on the day of infection 1 ~ 2. They often have severe anemia, persistent hypertension, renal insufficiency, sometimes accompanied by cardiac and fundus changes and coagulation of urine specific gravity. B-ultrasound sometimes shows that both kidneys are small.

prevent

The fundamental prevention is to prevent and treat streptococcal infection. On weekdays, we should strengthen exercise, pay attention to skin cleanliness and hygiene, and reduce respiratory tract and skin infections. Once infected, it should be treated promptly and thoroughly. 2 ~ 3 weeks after infection, urine routine should be checked to find abnormalities in time. L0 good ways to care for the kidney [2] 1. The survey of keeping warm in winter shows that the number of patients with renal function deterioration in winter far exceeds that in other seasons, mainly due to vasoconstriction, soaring blood pressure, decreased urine volume and strong coagulation at low temperature, which is easy to cause kidney problems. 2. Don't take medicine indiscriminately. Many commercially available painkillers, cold medicines and Chinese herbal medicines are nephrotoxic. Don't eat them without a doctor's prescription. You should also know the side effects of antibiotics and painkillers prescribed by doctors. 3. Don't overeat, too much protein and salt will increase the burden on the kidneys. In addition, sports drinks contain electrolytes and salts, so people with kidney diseases should be careful with these drinks. 4, treatment of colds If a cold goes and comes again, or after a cold, there is high blood pressure, edema, and blisters, it is best to find a nephrologist for screening. 5, recurrent tonsillitis should be careful when the throat or tonsil is infected by Streptococcus, it must be cured, otherwise it will easily lead to kidney inflammation. 6, moderate drinking water does not urinate urine stays in the bladder, just like the sewer is blocked, it is easy to breed bacteria, bacteria will infect the kidney through the ureter. 7. Control diabetes and hypertension. If the blood pressure is not well controlled, diabetes will cause arteriosclerosis for too long, and the kidney is composed of millions of microvascular balls. Blood sugar and blood pressure are not well controlled, and the kidney is bad quickly. 8. Don't drink well water and river water with unknown composition, so as to avoid injury caused by high content of heavy metals such as lead, cadmium and chromium. Kidney. 9. It is not that urinary calculi are painless, especially ureteral calculi are easy to cause hydronephrosis. Over time, the kidneys will be completely damaged unconsciously. 10, it is best to check urine creatinine and blood urea nitrogen every six months for regular physical examination. When a woman is pregnant, the burden on the kidney will increase, so the renal function should be monitored to avoid uremia caused by toxemia of pregnancy.

prognosis

The prognosis of acute nephritis in children is good. In 1950s, it was reported that the mortality rate of hospitalized children was as high as 5% (due to pulmonary edema, hypertensive encephalopathy, acute renal failure and infection). In recent years, due to the improvement of diagnosis and treatment, the mortality rate of hospitalized children has dropped below 0.5% ~ 2.0%, and some cities have eliminated acute death, the main cause of death is renal failure. Most of the children's gross hematuria disappeared within 2 ~ 4 weeks, diuresis and detumescence, blood pressure gradually recovered, a small amount of residual proteinuria and microscopic hematuria disappeared over 6 months, and a few of them were delayed by 1 ~ 3 years, but most of them could still recover.