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Previous reports of outbreaks of acute post streptococcal glomerulonephritis due to S. zooepidemicus.
Source publication
Background:
Scarce information on outcomes of epidemic post infectious glomerulonephritis is available. This is a 10-year follow-up of the patients that developed acute glomerulonephritis in an epidemic outbreak caused by group C Streptococcus zooepidemicus in Brazil in 1998, that were also previously evaluated 2 and 5 years after the acute episod...
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Citations
... [3] Kidney damage may persist years after PSGN because of secondary inflammation after infection due to the nephron's damages. [16] However, our patient was anuric, after daily dialysis, pathology specimen didn't reported cresentric and his symptoms start regretting. ...
... APSGN generally has a favorable prognosis with less than 1% of children progressing to end-stage renal failure[37]. A 7-year follow-up of children with acute glomerulonephritis in Iran reported that none of the patients had hypertension or renal impairments, 3.1% had proteinuria, and 6.3% had microscopic hematuria [38]. Furthermore, a 10-year follow-up of the children that developed APSGN in Brazil demonstrated an increase in the frequency of hypertension in APSGN groups compared to control groups but no significant difference in renal function evaluation which includes serum creatinine, cystatin C, eGFR, albuminuria, and hematuria [39]. ...
Acute post-streptococcal glomerulonephritis (APSGN) is the major cause of acute glomerulonephritis among children, especially in low- and middle-income countries. APSGN commonly occurs following pharyngitis due to the activation of antibodies and complements proteins against streptococcal antigens through the immune-complex-mediated mechanism. APSGN can be presented as acute nephritic syndrome, nephrotic syndrome, and rapidly progressive glomerulonephritis, or it may be subclinical. The management of APSGN is mainly supportive in nature with fluid restriction, anti-hypertensives, diuretics, and renal replacement therapy with dialysis, when necessary, as the disease is self-limiting. Congestive heart failure, pulmonary edema, and severe hypertension-induced encephalopathy might occur during the acute phase of APSGN due to hypervolemia. APSGN generally has a favorable prognosis with only a small percentage of patients with persistent urinary abnormalities, persistent hypertension, and chronic kidney disease after the acute episode of APSGN. Decreased complement levels, increased C-reactive protein, and hypoalbuminemia are associated with disease severity. Crescent formations on renal biopsy and renal insufficiency on presentation may be the predictors of disease severity and poor outcomes in APSGN in children.
... 1-3 Therefore, we followed up with patients affected by a large glomerulonephritis (GN) epidemic associated with Lancefield group C Streptococcus zooepidemicus in Minas Gerais, Brazil since 1998. [3][4][5][6] In 1998, 152 patients presented with fever, headache, and myalgia, followed by cervical adenopathy in a rural region near the city of Nova Serrana, in Minas Gerais, the second most populated Brazilian state. Then, 134 patients developed GN 7 to 10 days after the infection. ...
... 6 An improvement of the eGFR was observed 10 years after the outbreak, with mean levels a little more than those after 2 years of the disease onset, and associated with a decreased proportion of patients with albuminuria and increased hypertension rates. 3 Although PSGN has a good prognosis in children, 1,7-11 few studies have focused on the long-term outcome in adult patients. 6,12,13 PSGN following epidemic infections in adults seems to be associated with a higher risk of chronic renal complications. ...
... 6,12,13 PSGN following epidemic infections in adults seems to be associated with a higher risk of chronic renal complications. 3,6,14,15 Nevertheless, few studies with ample follow-up time have focused on PSGN in adult patients with nongroup A streptococcal strain. 16,17 This study describes the follow-up of patients with PSGN due to S zooepidemicus 20 years after the acute episode. ...
Introduction
Post-streptococcal glomerulonephritis (PSGN) has a good prognosis in children, but few studies have evaluated the long-term renal outcomes in adults with PSGN.
Methods
In a follow-up study, 47 predominantly adult patients with PSGN due to group C Streptococcus zooepidemicus were reassessed 20 years after an outbreak in Nova Serrana, Brazil. We evaluated clinical characteristics, renal outcomes, and the trajectory of the estimated glomerular filtration rate (eGFR) by the creatinine-based chronic kidney disease-epidemiology collaboration equation from 5 follow-up assessments. Logistic regression and mixed-effects regression were used in the analysis.
Results
After 20 years, the participants’ mean age was 56.6±15.1 years. Thirty-four (72%) patients had hypertension, 21 (44.7%) had eGFR <60 ml/min per 1.73 m², 8 of 43 (18.6%) had urine protein-to-creatinine ratio >150 mg/g, and 25 (53%) had CKD (low eGFR and/or increased proteinuria). Increasing age was associated with CKD (odds ratio: 1.07; 95% confidence interval [CI]: 1.02–1.13; P = 0.011) in multivariate analysis. The mean eGFR decline in the last 11 years of follow-up was −3.2 ml/min per 1.73 m² per year (95% CI: −3.7 to −2.7). Older age at baseline (coefficient −1.05 ml/min per 1.73 m² per year; 95% CI −1.28 to −0.81; P < 0.001), and hypertension 5 years after the outbreak (coefficient −7.78 ml/min/1.73 m²; 95% CI −14.67 to −0.78; P = 0.027) were associated with lower eGFR during the whole study period.
Conclusion
There was a marked worsening of renal function and a high prevalence of CKD and hypertension after 20 years of PSGN outbreak. Long-term follow-up is warranted after PSGN, especially among older patients.
... Se describe insuficiencia renal aguda en 25-30% de los pacientes, pero menos del 5% de ellos, requieren de tratamiento dialítico. Puede llevar a la insuficiencia renal crónica en 1% de los casos (23,34) . ...
La glomerulonefritis pos infecciosa (GNPI) es la principal causa de glomerulonefritis en pediatría. Puede producirse por una gran variedad de bacterias, virus, parásitos y hongos. La prevalencia de GNPI está disminuyendo en países desarrollados por mejoría de las condiciones sanitarias, por el diagnóstico precoz y por el uso de antibióticos. Afecta principalmente a los niños de 4 a 14 años, siendo infrecuente por debajo de los 3 años de edad. Es más frecuente en el sexo masculino. Se manifiesta como síndrome nefrítico agudo con la presencia de hematuria, hipertensión arterial e insuficiencia renal aguda. Se caracteriza por presentar C3 bajo que se normaliza a las 8 semanas de evolución. Las complicaciones son: insuficiencia renal aguda, edema agudo de pulmón y encefalopatía hipertensiva, estas 2 últimas producidas por sobrecarga de volumen. El tratamiento es de sostén, con la administración de diuréticos y restricción hídrica. En la mayoría de los casos, se presenta una recuperación clínica espontánea y completa, y el pronóstico ha sido considerado excelente. Sin embargo, algunos estudios sugieren que la enfermedad podría producir daño renal crónico. Se describe la evolución hacia la enfermedad renal crónica en 1% de los casos.
... The prognosis of APSGN is relatively benign in the low-risk populations; however, it is associated with a 5-to 6-fold increased risk of CKD in resource-limited settings. 2,20 The incidence of APSGN has declined globally in the past four decades and particularly in some developed countries. 10,17 Acute post-streptococcal glomerulonephritis, however, remains an important health problem in developing countries and tropical regions of a number of developed countries. ...
Acute post-streptococcal glomerulonephritis (APSGN) is an inflammatory kidney disease following infection with nephritogenic strains of group A Streptococcus. In 1991, APSGN became notifiable in the Northern Territory (NT) of Australia with cases recorded on the NT Notifiable Disease Database (NTNDS). The case definition of a confirmed case requires laboratory definitive evidence or laboratory suggestive evidence in conjunction with a clinically compatible illness. Probable cases require clinical evidence only. Acute post-streptococcal glomerulonephritis notifications from 2009 to 2016 were extracted from the NTNDS. Of the 322 cases, 261 were confirmed and 61 probable. The majority, 304 (94%), were Aboriginal and the median age was 8 years (range: 0-62 years). Incidence for confirmed cases was 13.8/100,000 person-years, with inclusion of probable cases increasing incidence to 17.0/100,000 person-years. Highest incidence of confirmed cases was in Aboriginal children less than 15 years of age at 124.0 cases/100,000 person-years. The rate ratio of confirmed cases in Aboriginal to non-Aboriginal Australians was 18.9 (95% confidence interval: 11.4-33.6). Recent trends show a consistently high number of notifications annually with less frequent outbreaks. The Aboriginal population of the NT continues to have high rates of APSGN with recent trends showing higher rates than previously reported. Sustained preventative efforts and continued surveillance strategies are needed.
... There were 4 mortalities in the acute phase and 5 patients (3.7%) required chronic dialysis. Follow up was continued for 10 years and demonstrated morbidity with patients developing hypertension, reduced renal function, and increased microalbuminuria which peaked within the first 2 years with subsequent stabilization [14,15]. A unique feature of this case is that the patient had two streptococcal infections. ...
Streptococcus anginosus
is a clinically important pathogen that is emerging globally but remains poorly investigated. Here, we report the first case of acute glomerulonephritis resulting from infection with S.anginosus. Glomerulonephritis is typically caused by S. pyogenes and reports secondary to other strains including S. zooepidemicus and S. constellatus exist. Infection with S. anginosus in this patient was associated with acute nephritis (haematuria, oedema and hypertension), nephrotic syndrome and progressive azotemia. There was activation of the complement system. The presence of low C1q and elevated anti-C1q binding complexes points to a potential pathogenic role. Testing for streptococcal antigens was strongly positive. Emerging nephritogenic strains of S. anginosus present a significant health concern for both developed and developing countries.
... In a 10-year follow-up study of Brazilian children with PSGN, hypertension was twice more prevalent in those with PSGN than in controls. There was no significant difference in renal function, haematuria or proteinuria [64]. Isolated microscopic haematuria might, however, continue for some months [65]. ...
Post-infectious glomerulonephritis (PIGN) is one of the most common causes of acute glomerulonephritis in children. Although post-streptococcal glomerulonephritis (PSGN) is still common, there is a wide spectrum of causative agents of PIGN. Non-streptococcal organisms are emerging as the main aetiological agents in high-income countries. Nephritis-associated plasmin receptor (NAPlr) and streptococcal pyrogenic exotoxin B (SPeB) are the two common antigens implicated in the pathogenesis of PSGN. Both NAPlr and SPeB activate the alternative complement pathway, resulting in low serum complement levels, and have an affinity to plasmin and glomerular proteins. The clinical presentation of PIGN varies from a benign asymptomatic condition to rapidly progressive glomerulonephritis requiring dialysis. In most cases, PIGN is self-limiting and the evidence base for the treatments used is quite weak. Renal biopsy is indicated when there are atypical features, rapid progression or inadequate recovery, or where an alternative diagnosis has to be considered. IgA-dominant nephritis, endocarditis-associated nephritis and shunt nephritis are special sub-subtypes of PIGN. The prognosis is generally excellent, although long-term follow-up may be needed.
... The PSGN patients in our series who had positive ANA or ANCA titers had particularly severe courses which often included the need for acute hemodialysis. On review of the literature a cluster of severe postinfectious glomerulonephritis cases was reported in Brazil following outbreak caused by group C Streptococcus zooepidemicus [20]. The frequency of severe PSGN over time from group A organisms has not been studied to our knowledge; however other populations did report the association between severe PSGN and increased ANCA levels [21]. ...
The most common acute glomerulonephritis in children is poststreptococcal glomerulonephritis (PSGN) usually occurring between 3 and 12 years old. Hypertension and gross hematuria are common presenting symptoms. Most PSGN patients do not experience complications, but rapidly progressive glomerulonephritis and hypertensive encephalopathy have been reported. This paper reports 17 patients seen in 1 year for PSGN including 4 with atypical PSGN, at a pediatric tertiary care center. Seventeen children (11 males), mean age of 8 years, were analyzed. Ninety-four percent had elevated serum BUN levels and decreased GFR. Four of the hospitalized patients had complex presentations that included AKI along with positive ANA or ANCAs. Three patients required renal replacement therapy and two were thrombocytopenic. PSGN usually does not occur as a severe nephritis. Over the 12-month study period, 17 cases associated with low serum albumin in 53%, acute kidney injury in 94%, and thrombocytopenia in 18% were treated. The presentation of PSGN may be severe and in a small subset have associations similar to SLE nephritis findings including AKI, positive ANA, and hematological anomalies.
... A Tunisian study by Hamouda M et.al and an Indian study by Natarajan G. et.al showed similar findings but both studies had younger adult patients (mean age of 36 years and 32 years respectively) with lower rates of comorbidities and mainly presented with URTI [14,15]. Natarajan G et.al. ...
... A study by Lou at.al among Chinese patients with a long follow up showed no significant sequelae [14]. A recent study of Brazilians by Pinto et.al with 10 years follow up showed complete recovery in most of the patients except for a few with albuminuria and hypertension as the sequelae [15]. In contrast, our study showed almost 50% of patients ended up on long-term dialysis and a significant number only partially recovered with persisting CKD. ...
Aim:
Acute post infectious glomerulonephritis is common in Indigenous communities in the Northern Territory, Australia. It is a major risk factor for the high prevalence of chronic kidney disease. We aimed to analyse the clinical presentation, pathological spectra, treatment and outcomes of biopsy-proven acute post infectious glomerulonephritis in the Northern Territory.
Methods:
We performed a retrospective cohort analysis of all adult patients (≥18 years) who were diagnosed with acute post infectious glomerulonephritis on native renal biopsies from 01/01/2004 to 31/05/2014. The outcome measure was end stage renal disease requiring long-term dialysis.
Results:
Forty-three of 340 patients who had renal biopsies had acute post infectious glomerulonephritis. Most were Aboriginals (88.4%). They had comorbidities; diabetes mellitus (60.5%), hypertension (60.5%) and smoking (56.4%). 49% had multiple pathologies on biopsy. Predominant histological pattern was diffuse proliferative glomerulonephritis (72%). Main sites of infections were skin (47.6%) and upper respiratory tract infection (26.2%) with streptococcus and staphylococcus as predominant organisms. Fifty percent of patients developed end stage renal disease. On multivariable logistic regression analysis, those on dialysis had higher baseline creatinine (p = 0.003), higher albumin/creatinine ratio at presentation (p = 0.023), higher serum creatinine at presentation (p = 0.02), and lower estimated glomerular filtration rate at presentation (p = 0.012).
Conclusion:
Overall, most patients had pre-existing pathology with superimposed acute post infectious glomerulonephritis that led to poor outcomes in our cohort.
