A 28-year-old man from rural India presents with gross haematuria, mild oedema, and hypertension (BP 148/92 mmHg) 10 days after a throat infection. Serum creatinine is 1.2 mg/dL, and urinalysis shows RBC casts and proteinuria (1.5 g/day). Complement levels (C3 and C4) are normal. Renal ultrasound is normal. What is the most appropriate next step in management?
A. Start oral corticosteroids 1 mg/kg/day
B. Perform renal biopsy immediately
C. Initiate supportive care with salt restriction, antihypertensives, and diuretics if needed; monitor renal function and urinalysis weekly
D. Start immunosuppression with cyclophosphamide
Explanation
Clinical Presentation Analysis
This patient presents with classic features of post-streptococcal glomerulonephritis (PSGN):
Normal complement levels (C3, C4) — important clue ruling out other GN types
Mild renal impairment (Cr 1.2)
Normal renal ultrasound
Management Strategy for PSGN
Key Point
PSGN is typically self-limited and managed conservatively in most cases. The prognosis is excellent in children and generally good in adults.
High-YieldNEET PG
The cornerstone of PSGN management is supportive care, not immunosuppression. Most patients recover spontaneously within 4–12 weeks.
Supportive Care Components
1.
Salt restriction — reduces volume overload and hypertension
2.
Antihypertensives — control BP (ACE inhibitors or ARBs preferred for renal protection)
3.
Diuretics — if oedema or pulmonary congestion present
4.
Close monitoring — weekly urinalysis and serum creatinine to track recovery
5.
Dietary protein — modest restriction if Cr significantly elevated
Why NOT Other Options?
Renal biopsy is NOT indicated at presentation in suspected PSGN with:
Clinical diagnosis supported by post-infectious history
Normal complement levels
Stable renal function
No atypical features (e.g., rapid decline, absence of haematuria)
Biopsy is reserved for:
Diagnostic uncertainty
Rapidly progressive renal failure
Absence of haematuria (atypical presentation)
No improvement after 3 months
Corticosteroids and immunosuppression are NOT first-line because:
PSGN resolves spontaneously in >95% of adults
No evidence of benefit from steroids in uncomplicated PSGN
Reserved for rare complications (crescentic disease, severe renal failure)
Clinical Pearl
The normal C3 level is reassuring and virtually excludes membranoproliferative GN and lupus nephritis, which present with C3 depression. This finding strongly supports PSGN and argues against aggressive immunosuppression.
Monitoring Endpoints
Haematuria typically resolves within 3–6 weeks
Proteinuria may persist longer (up to 6 months)
Hypertension usually normalizes with salt restriction and diuretics
Serum creatinine should return to baseline
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