Pediatric emergency medicine trisk 2899 2899
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Eighty-five percent of cases of nephritis will present within 4 weeks after
the onset of systemic symptoms, and it is rare for nephritis to develop later
than 6 months after presentation. Upon presentation to the ED, a urinalysis
should be obtained to evaluate for hematuria and proteinuria. If this study is
normal, no further laboratory evaluation, such as evaluation of serum
electrolytes or renal function, is indicated. Patients will require regular
follow-up with their primary care providers for serial urinalysis and
monitoring of blood pressures. Generally, if the urinalyses remain normal
during the initial 6-month period, there is no need to screen for renal
disease thereafter. Children presenting with clinical evidence of nephritis
such as hematuria, edema, and hypertension warrant laboratory evaluation
including serum electrolytes, BUN, creatinine, and albumin in addition to
urinalysis.
Management. Most patients with HSP and associated nephritis require
only supportive care, including hydration and pain control. Hospitalization
may be required for uncontrolled pain, significant gastrointestinal bleeding,
surgical abdomen, or AKI. If hypertension is present, short- or long-acting
calcium channel blockers can be used. ACE inhibitors may be used to
reduce proteinuria. Patients with HSP nephritis should undergo regular
evaluation to screen for signs of progressive renal disease, such as
worsening proteinuria, decreasing renal function, and hypertension.
Once HSP has developed, corticosteroids may be indicated for severe
gastrointestinal symptoms. Their efficacy in preventing nephritis has not
been proven, however, and should not be started for this indication.
The optimal treatment of children with extensive renal disease remains
controversial. Prior to initiating therapy, a nephrologist should be consulted
and a renal biopsy may need to be obtained to determine the extent of
crescent formation, as this appears to be the best indicator of prognosis.
Though data are limited given the rarity of severe HSP nephritis, aggressive
therapy may be beneficial in patients with severe disease. These patients
may benefit from treatment with steroids with or without other agents such
as azathioprine, cyclophosphamide, and anticoagulants, but treatment
should occur under the care of a nephrologist.
In children without HSP nephritis, symptoms often resolve within 1
month. One-third of patients may have recurrent symptoms, especially
within the first 4 months. There is little risk of long-term impairment in
