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Clinical Practice Guidelines

Post-streptococcal glomerulonephritis (PSGN)

  • See also

    Nephrotic syndrome 

    Hypertension 

    Henoch-Schonlein purpura

    Key points

    1. Post-streptococcal glomerulonephritis (PSGN) is generally a mild, self-limiting condition, however it has been recognised as a strong risk factor for chronic kidney disease in Aboriginal and Torres Strait Islander people
    2. Priorities of treatment include blood pressure and oedema management and early identification of complications
    3. Most cases can be managed locally with close follow-up to ensure resolution by 8 weeks (noting that microscopic haematuria may persist for up to 2 years)

    Background

    • PSGN is the most common cause of acquired glomerulonephritis in children
    • The disease commonly occurs 2-4 weeks following an acute group A Streptococcal infection (usually pharyngitis or impetigo)
    • The incidence of PSGN is much higher in Aboriginal and Torres Strait Islander populations

    Assessment

    Children with PSGN can present with a variety of symptoms, the classical triad being:

    • Hypertension
    • Haematuria (may be macroscopic or microscopic)
    • Oedema

    Initial assessment should exclude any end-organ dysfunction including an assessment of ABCs

    Red flags

    Children with any of the below features require urgent management, discussion with retrieval services, paediatric nephrology and/or intensive care:

    • Severe hypertension (>95th centile + 30 mmHg for gender/age/height) with or without evidence of end organ dysfunction
    • Critical electrolyte abnormalities (generally hyperkalaemia and acidosis)
    • Evidence of pulmonary oedema
    • Anuria or oliguria (<0.5 mL/kg/hr of urine output) despite adequate intravascular volume
    • Persistently rising creatinine, oliguria/anuria, acidosis, refractory hyperkalaemia and hypertension can be indicators of rapidly progressive glomerulonephritis (RPGN)

    History

    • Recent or intercurrent streptococcal infection
    • Swelling/oedema
    • Colour and volume of urine
    • Headache, altered mental state, blurred vision, vomiting
    • Oedema: shortness of breath, swelling
    • Cardiac: chest pain, palpitations
    • Previous episodes of macroscopic or microscopic haematuria may be indicative of IgA nephropathy or Alport syndrome (especially in the presence of family history of kidney disease at a young age)
    • Previous history of rashes, swollen joints or other systemic symptoms may be suggestive of underlying lupus nephritis or IgA vasculitis nephritis eg Henoch-Schonlein purpura, which can also occur post streptococcal infection

    Examination

    • Growth parameters and comparison to pre-illness weight (may be an isolated sign of fluid overload in absence of oedema)
    • Blood pressure (use age and gender reference ranges), confirm with manual measurement, see Hypertension
    • Fluid and oedema assessment (degree of fluid overload and estimation of intravascular volume depletion)
    • Signs of pulmonary oedema
    • End organ effects of hypertension (hypertensive retinopathy, cardiac failure, facial nerve palsy, encephalopathy)

    Management

    Investigations

    • Urine dipstick
    • Urine MCS
    • Spot urine protein/creatinine ratio
    • FBE
    • UEC, LFTs, serum albumin
    • Complement C3, C4
    • Anti-streptococcal antibodies: ASOT +/- anti-DNAse B (depending on laboratory availability)

    Consider

    • Throat and/or skin swabs for MCS if signs of acute Streptococcal infection
    • Chest X-ray (if any concerns for pleural effusion or pulmonary oedema)
    • Renal tract ultrasound (including doppler) in cases of unclear diagnosis, significant flank or abdominal pain, atypical history or poor response to diuretics eg congenital malformations, renal vein thrombus
    • Blood culture, if febrile, or systemically unwell

    If raised creatinine, atypical history, or concern for systemic disease, consider further testing for autoimmune disease in discussion with nephrology and rheumatology

    Treatment

    • Strict fluid balance with daily weights (taken at same time on same scales)
    • Monitor urine output in mL/kg/hr
    Assessment Management
    Clinical signs of fluid overload and oedema

    Furosemide 0.5-1 mg/kg (max 40 mg) IV/oral 12H

    Consider IV dosing if child is very oedematous as gut oedema could impair absorption. Change to PRN dosing as fluid overload improves, and discontinue when child is no longer oedematous and/or back to pre-illness weight

    Low or no-added salt diet

    Fluid restrict to 750 mL/m2/day (about ½ maintenance fluids)
    Evidence of active Streptococcal infection

    Antibiotics as per local guidance

    Consider familial contact tracing, prophylaxis and eradication in accordance with local infectious diseases and public health guidelines (PSGN is a notifiable condition in some health services)
    Acute kidney injury

    Calculate eGFR (using revised Schwartz formula). For children >2 years:

    eGFR = [height (cm) x 36.5] / serum creatinine (µmol/L)

    Adjust medications as required. If raised creatinine on presentation, monitor blood tests to ensure not progressing to RPGN
    Hypertension

    Target systolic blood pressure (SBP) <95th centile for age, sex and height (see percentile charts for girls and boys)

    Mostly driven by fluid overload and commencement of furosemide will treat hypertension

    If SBP is >95th centile (on two measurements 1 hr apart), use PRN doses of immediate release nifedipine 0.25 mg/kg (max 20 mg) oral every 6 hours

    After day 2, if still requiring >2 doses of nifedipine per day, commence regular amlodipine 0.1 mg/kg/day, can increase to 0.6 mg/kg/day (max 10 mg) and utilise PRN nifedipine as a titrating agent

    Consider consultation with local paediatric team when

    • Child is suspected to have PSGN

    A large number of PSGN cases occur in geographically isolated regions and may present to rural and remote health services. To facilitate family-centred and culturally safe care, most PSGN can and should be managed by the local (or closest) paediatric service

    Consider consultation with paediatric nephrology when

    • Any red flag features are present
    • Hypertension requiring multiple agents

    Consider transfer when

    • Early evidence of significant renal impairment or systemic illness outside of what would be expected for PSGN
    • Children requiring care beyond the level of comfort of the local hospital

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    Blood pressure and renal function stabilise or start improving and child is at or near baseline weight

    • Child should not require ongoing furosemide at home, but may require BP control with another agent

    Follow-up arrangements

    Arrange weekly follow-up to monitor blood pressure and urinalysis

    General paediatric review 8 weeks after initial presentation

    • Aim to wean off anti-hypertensives as able (generally achievable within 6 weeks of presentation)
    • Repeat bloods including C3/C4 and renal function at 8 weeks
    • Microscopic haematuria and intermittent proteinuria may persist for up to 2 years (this should not be macroscopic haematuria, >3+ proteinuria or increasing over time)
    • A small number of children can have persistent low-grade urinary changes (microscopic haematuria, proteinuria) that are usually benign and do not lead to chronic kidney disease

    Discuss with paediatric nephrology (for consideration of renal biopsy) if any of the following are identified during follow-up

    • macroscopic haematuria persists >5 days from initial presentation or recurs
    • signs of acute nephritic syndrome (haematuria, proteinuria, oedema, hypertension, oliguria)
    • signs of nephrotic syndrome (proteinuria, hypoalbuminaemia, oedema)
    • blood pressure persistently >95th percentile for age, sex, height
    • unable to wean anti-hypertensive medication by 8 weeks
    • repeat blood tests at 8 weeks show persistently low C3 and/or abnormal renal function
    • proteinuria increasing over time
    • persistent proteinuria, defined as an early morning urine protein/creatinine ratio:
      • >200 mg/mmol for 4 weeks
      • >100 mg/mmol for 3 months
      • >50 mg/mmol for 6 months

    Parent information

    Poststreptococcal Glomerulonephritis (PSGN) | KidsHealth NZ

    Last updated June 2025

    Reference List

    1. Hoy WE. Post-streptococcal glomerulonephritis is a strong risk factor for chronic kidney disease in later life. Kidney International. 81 (10), 1026-1032.
    2. KDIGO Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney International. 2021. 100 (4S), S1-S276.
    3. Ong LT. Management and outcomes of acute post-streptococcal glomerulonephritis in children. World J Nephrol. 2022. 11 (5), 139-14.