Nephritis and Nephrosis
Authors: G. C. Arneil
Journal: BMJ (1965)

Bright's disease is so bedevilled by differing classifications that the medical practitioner cannot but be confused.For clarity I have adopted the following simple scheme:(1) Pyelonephritis (2) Haemorrhagic nephritis (3) The nephrotic syndrome (4) Hypertensive states Chronic renal failure (" chronic nephritis ")In childhood the most important groups are pyelonephritis, haemorrhagic nephritis, and the nephrotic syndrome, in that order.Pyelonephritis is discussed elsewhere in this series. Haemorrhagic Nephritis Acute NephritisThis is a bilateral disease of the kidneys occurring most commonly in the child of school age.Approximately 85% of cases have associated infection with Lancefield group A, fl-haemolytic streptococci.The patient usually presents with a complaint of passing brown urine.The urine may be tested for haemoglobin by tablet tests such as Occultest.The smoky colour of nephritic urine is related to the presence of lysed cells.Microscopic examination is essential to observe the red cells, cellular casts, and white blood cells which will be present in excess.The second commonest cause of haematuria in children is acute pyelonephritis, and one should be on guard against this possibility if frequency or dysuria is complained of.Periorbital * Leonard Gow Lecturer in Child Health, University of Glasgow.oedema or enlarged cervical glands may have been noted.A complaint of headache or blurring of vision is a likely indication of severe and potentially dangerous hypertension.A story of a preceding respiratory infection may be obtained.The general examination of the patient includes inspection of the skin for concomitant rash (purpuric or scarlatiniforni).Periorbital oedema is often present and generalized oedema occasionally present.Examination of the cardiovascular system is particularly important.By 1958 it had become clear to us that a characteristic feature of acute nephritis was expansion of the blood volume accounting for temporary cardiomegaly and believed to be due to sodium retention and poor kidney function in water excretion.That increase in extra- cellular fluid is not usually accompanied by an increase in body weight even when oedema is present presumably is in part due to a shift of fluid within the body compartments.This " hypertonic " hypervolaemia is visible on radiographs of the chest as engorgement of the lung fields, enlargement of the heart, and sometimes as congestive cardiac failure (Fig. 1).To avoid aggravating the "hypertonic" hypervolaemia it is important to reduce the amount of sodium (salt) and water in the patient's diet.Another possible cardiovascular complication is severe hypertension.The blood-pressure should be recorded at least once daily for the first week of illness until it settles as diuresis occurs.If a general practitioner is not in a position to carry out daily recording of blood-pressure, then the child is better in hospital.Attention is principally focused on the diastolic blood- pressure.If this rises above 100 mm./Hg in a child with acute nephritis, phenobarbitone should be given (gr.1-1 (30-60 FIG.1.-Alteration in cardiac and pulmonary vascular pattern in acute nephritis.These manifestations of hypervolaemia are frequently unrecog- nized.Note the cardiac enlargement and pulmonary plethora in (a).The second radiograph (b) was taken one week later.During this week diuresis occurred and hypertension ceased.