Clinical Characteristics and Outcome of Post-Infectious Glomerulonephritis in Children in Southern India: A Prospective Study

Clinical Spectrum of Acute Post-streptococcal Glomerulonephritis in Children: A Kashmir Experience

Background In the pediatric population, acute post-streptococcal glomerulonephritis (PSGN) is a common glomerular etiology of hematuria and acute hypertension leading to hospitalization. We conducted this study to know the clinical profile and occurrence of acute PSGN in patients presenting with features of acute nephritic syndrome. Methods This prospective observational study was conducted on children aged between two and 18 years, presenting with clinical features of acute glomerular nephritis (AGN). After due ethical considerations, all eligible patients were enrolled and underwent detailed clinical assessment, laboratory, and imaging evaluation, followed by protocolized treatment. Relevant data were collected and analyzed to reach valid results. Results Out of 60 patients with AGN, PSGN was found in 83.3% of the patients (50/60). The age group under five years was the most commonly involved, with a male/female ratio of 1.6:1. Around half of the studied patients were from the lower middle class, and 40 (80%) were from rural backgrounds. Facial puffiness was the most common clinical presentation, seen in 45 (90%) patients. Hypocomplementemia and proteinuria were seen in all PSGN patients. Pyoderma was the most common preceding infection, seen in 38 (76%) patients, followed by pharyngitis. Acute kidney injury (AKI) was the most common complication, seen in 12 (24%) patients. Complete resolution of the signs and symptoms was seen in 37 (74%) patients at the time of discharge, which increased to 47 (94%) patients at six months post discharge. Conclusion PSGN stands to be the most common cause of pediatric AGN. The population under five years of age, with a past history of pyoderma, is more predisposed to PSGN. The potential for the occurrence of AKI and other life-threatening complications is high, for which early diagnosis and institution of proper treatment would be very beneficial.

Acute Post-infectious Glomerulonephritis in Children Admitted to a Tertiary Care Hospital: A Descriptive Cross-sectional Study

INTRODUCTION

Post infectious glomerulonephritis remains the most common cause leading to the majority of hospital admissions in children of developing countries like ours. The aim of our study was to find the prevalence of post infectious glomerulonephritis, study the clinical profile, biochemical changes and its complication in children admitted in a tertiary care hospital of Nepal.

METHODS

This descriptive cross-sectional study of children admitted at a tertiary care hospital was done from May 2020 till May 2023. A census sampling method was used and sample of 1554 children was taken. Detailed socio demographic data, clinical findings and laboratory investigations were done. Data analysis was done using SPSS software and the results obtained are shown in the form of frequencies along with percentages.

RESULTS

Among 1554 patients, the prevalence of acute post-infectious glomerulonephritis was found to be 63 (4.05%) (3.07-5.03 at 95% Confidence Interval). The mean age of the patients was 9.06±3.48 years. Antistreptolysin O titer was raised in 34 (54%) patients, while low serum C3 was observed in 39 (61.90%) patients with acute post-infectious glomerulonephritis.

CONCLUSIONS

Acute post-infectious glomerulonephritis (APIGN) remains a notable health concern in children, particularly in developing countries like Nepal. This highlights the need for ongoing surveillance, prevention strategies, and effective management protocols to address this burden effectively.

Infection-Related Glomerulonephritis in Children and Adults

Infection-related glomerulonephritis is an immunologically mediated glomerular injury after an infection. Glomerulonephritis may occur with the infection or after a variable latent period. Poststreptococcal glomerulonephritis (PSGN) is the prototype of infection-related glomerulonephritis. The streptococcal antigens, nephritis-associated plasmin-like receptor and streptococcal exotoxin B, have emerged as major players in the pathogenesis of PSGN. Although PSGN is the most common infection-related glomerulonephritis in children, in adults, glomerulonephritis is secondary to bacteria such as staphylococci, viruses such as hepatitis C, and human immunodeficiency virus, and, rarely, parasitic infections. Supportive therapy is the mainstay of treatment in most infection-related glomerulonephritis. Treatment of the underlying infection with specific antibiotics and antiviral medications is indicated in some infections. Parasitic infections, although rare, may be associated with significant morbidity. Poststreptococcal glomerulonephritis is a self-limiting condition with a good prognosis. However, bacterial, viral, and parasitic infections may be associated with significant morbidity and long-term consequences. Epidemiologic studies are required to assess the global burden of infection-related glomerulonephritis. A better understanding of the pathogenesis of infection-related glomerulonephritis may unravel more treatment options and preventive strategies.

Acute Postinfectious Glomerulonephritis

Postinfectious glomerulonephritis (PIGN) is a leading cause of acute glomerulonephritis in children. The presentation of PIGN can vary from asymptomatic microscopic hematuria incidentally detected on routine urinalysis to nephritic syndrome and a rapidly progressive glomerulonephritis. Treatment involves supportive care with salt and water restriction, and the use of diuretic and/or antihypertensive medication, depending on the severity of fluid retention and the presence of hypertension. PIGN resolves completely and spontaneously in most children, and the long-term outcomes are typically good with preserved renal function and no recurrence.

Management and outcomes of acute post-streptococcal glomerulonephritis in children

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.

A 15-year-old with chest pain: An unexpected etiology

A 15-year-old female with no significant past medical history presented to the emergency department with 1 day of substernal and pleuritic chest pain, chills, cough, and hematuria. She also had swelling of the face and ankles that resolved by presentation. She was found to have elevated troponin and brain natriuretic peptide during initial workup. Electrocardiogram was normal, but there were significant pleural effusions on chest x-ray. She was strep positive and had blood pressure up to 150/90, prompting admission for cardiac monitoring and cardiology consultation. Blood pressure decreased down to 125/72 without intervention. She was afebrile with unlabored breathing and normal saturations. She was clear to auscultation bilaterally, with no abdominal distension or hepatosplenomegaly, and edema was not evident on exam. There was mild erythema to the bilateral tonsillar pillars. Initial considerations included viral myocarditis, pericarditis, and atypical nephritic syndrome. Workup revealed elevated antistreptolysin antibodies, low C3 complement, negative antineutrophil cytoplasmic antibodies, and negative flu testing. Renal sonography was unremarkable. Cardiology recommended echocardiography, which confirmed pleural effusions but revealed no cardiac abnormalities. Urinalysis revealed hematuria and mild proteinuria. Diagnosis was found to be post-streptococcal glomerulonephritis complicated by fluid overload and left ventricular strain secondary to hypertensive emergency. Post-streptococcal glomerulonephritis is the most common cause of acute glomerulonephritis in children. The mechanism of disease is a proliferation and inflammation of the renal glomeruli secondary to immunologic injury, with deposition of immune complexes, neutrophils, macrophages, and C3 after complement activation. This leads to hematuria, proteinuria, and fluid overload. Edema is present in 65%–90% of patients, progressing to pulmonary involvement in severe cases. Cardiac dysfunction secondary to fluid overload is a potentially fatal outcome in the acute setting. Physicians should consider post-streptococcal glomerulonephritis for patients presenting with hypertension, cardiac/pulmonary pathology, or symptoms of acute heart failure in the context of strep infection.

Clinical characteristics of acute glomerulonephritis with presentation of nephrotic syndrome at onset in children

BACKGROUND

Acute glomerulonephritis (AGN) is a common disease in children, which places a huge burden on developing countries. The prognosis of it may not always be good. However, the clinical characteristics of AGN with nephrotic syndrome (NS) at onset have not been fully clarified.

METHODS

One hundred and thirteen cases were analyzed retrospectively. Clinical data, pathological results and prognosis between AGN with NS (AGN-NS) and AGN without NS (AGN-no-NS) were compared.

RESULTS

Twenty (17.7%) of 113 patients were AGN-NS. The patients with AGN-NS were more likely to have hypertension (55.0% vs. 25.8%) and acute kidney injury (AKI) (50.0% vs. 17.2%). AKI was significantly related to the manifestation of AGN-NS in children (OR = 3.812, P = 0.040). Compared with the AGN-no-NS, the immunosuppressive treatments were more common in AGN-NS. A more severe pathological grade was significantly related to lower C3 fraction, estimated glomerular filtration rate (eGFR), and AKI, but not to the performance of AGN-NS. There was no difference in prognosis between the two groups.

CONCLUSIONS

AKI was significantly associated with AGN-NS. The prognosis of AGN-NS and AGN-no-NS in our study was almost good. Given the fact that AGN-NS patients are more likely to use immunosuppressive therapy, the long-term outcome of AGN-NS warrants further research.

Acute post-streptococcal glomerulonephritis in Central Australia

OBJECTIVE

To determine the incidence, clinical presentation and progress of acute post-streptococcal glomerulonephritis in Central Australia.

DESIGN

Retrospective observational analysis.

SETTING

Paediatric inpatient admission at Alice Springs Hospital.

PARTICIPANTS

Patients admitted to Alice Springs Hospital under 14 years of age meeting diagnostic criteria for acute post-streptococcal glomerulonephritis between January 2010 and December 2014.

MAIN OUTCOME MEASURES

Incidence of acute post-streptococcal glomerulonephritis in central Australia. Biochemical abnormalities associated with acute post-streptococcal glomerulonephritis. Co-occuring conditions.

RESULTS

Sixty-nine out of the 174 cases reviewed were identified as having either acute post-streptococcal glomerulonephritis (63) or probable acute post-streptococcal glomerulonephritis (6). We calculate the incidence of APSGN admission to be higher than previously reported and the highest reported incidence globally in children. Clinical evidence of skin infection was frequently documented. Co-occurring infections were common, including scabies/head lice, urinary tract infection and pneumonia. Fifty-three patients showed biochemical evidence of acute kidney injury.

CONCLUSIONS

Aboriginal children in Central Australia have the highest incidence of acute post-streptococcal glomerulonephritis reported worldwide. Urgent action is required to improve housing and reduce overcrowding in Central Australian towns and communities to reduce the burden of disease of skin infection and Group A Streptococcus related diseases. Without effective change in living conditions, it is unlikely that there will be a significant change in the morbidity related to these conditions.

Epidemiology, pathogenesis, treatment and outcomes of infection-associated glomerulonephritis

For over a century, acute 'post-streptococcal glomerulonephritis' (APSGN) was the prototypical form of bacterial infection-associated glomerulonephritis, typically occurring after resolution of infection and a distinct infection-free latent period. Other less common forms of infection-associated glomerulonephritides resulted from persistent bacteraemia in association with subacute bacterial endocarditis and shunt nephritis. However, a major paradigm shift in the epidemiology and bacteriology of infection-associated glomerulonephritides has occurred over the past few decades. The incidence of APSGN has sharply declined in the Western world, whereas the number of Staphylococcus infection-associated glomerulonephritis (SAGN) cases increased owing to a surge in drug-resistant Staphylococcus aureus infections, both in the hospital and community settings. These Staphylococcus infections range from superficial skin infections to deep-seated invasive infections such as endocarditis, which is on the rise among young adults owing to the ongoing intravenous drug use epidemic. SAGN is markedly different from APSGN in terms of its demographic profile, temporal association with active infection and disease outcomes. The diagnosis and management of SAGN is challenging because of the lack of unique histological features, the frequently occult nature of the underlying infection and the older age and co-morbidities in the affected patients. The emergence of multi-drug-resistant bacterial strains further complicates patient treatment.

Epidemiology and clinical outcomes of acute glomerulonephritis in a teaching hospital in North India

Context:

Acute glomerulonephritis (AGN) is a major cause of morbidity in developing countries like India. AGN includes both infectious and non infectious causes leading to immunological insult to the kidney.

Aims:

This study is an attempt to evaluate the clinical characteristics, complications and outcome of acute glomerulonephritis.

Settings and Design:

This hospital based descriptive study was conducted at a tertiary care hospital in North India. Materials and Methods: 50 children with AGN were recruited and analyzed over a period of one year. Detailed clinical examination and relevant laboratory investigations were done. Children were followed up for 6 months.

Statistical Analysis Used:

Data analysis was done using SPSS software and the results obtained are shown in the form of frequencies along with percentages.

Results:

50 patients were enrolled in the study with male to female ratio of 1.72:1. Pharyngitis was the most common predisposing condition (70.2%). 22(40.4%) of patients had developed complications. Of this acute kidney injury with significant pulmonary edema was seen in 16 patients and 6 patients had encephalopathy with seizures. Two patients had to be managed with hemodialysis. 42 patients had positive CRP (>10) and ASO titres were >200 Todd units in all patients. At 6 months’ majority of patients had complete clinical recovery with microscopic hematuria present only in 8 patients, persistent hypertension in 2 patients, 8 patients had proteinuria. These patients are being still followed up.

Conclusions:

Complications and morbidity is significantly high during the acute phase in AGN. Non infectious causes should also be kept in mind. This study highlights the complications requiring intensive care and need for long term follow up.

Acute Post-Streptococcal Glomerulonephritis in the Northern Territory of Australia: A Review of Data from 2009 to 2016 and Comparison with the Literature

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.

Spectrum of biopsy proven renal disease in South Asian children: Two decades at a tropical tertiary care centre

AIM

We report findings from a large single centre paediatric renal biopsy cohort in South Asia.

METHODS

We analyzed all renal biopsies performed on children aged ≤18 years between 1996 and 2015 at our centre. The clinical characteristics and histological diagnosis pertaining to each case, distribution of renal diseases in children with various clinical presentations, and changes in the pattern of kidney disease during the study period were analyzed.

RESULTS

A total of 1740 paediatric kidney biopsies were performed during the study period. The mean age was 12.8 ± 4.9 years (8 months to 18 years) and the male: female ratio was 1.5:1. The most common indication for renal biopsy was nephrotic syndrome (63.2%) followed by acute nephritic syndrome (13%). Minimal change disease was the most common cause of nephrotic syndrome while endocapillary proliferative glomerulonephritis (65.7% infection related), remained the commonest cause of acute nephritic syndrome. IgA nephropathy was the commonest cause of chronic kidney disease. Contrary to trends in European paediatric cohorts, the frequency of lupus nephritis increased over the two decades of the study, while that of endocapillary proliferative glomerulonephritis did not show any appreciable decline.

CONCLUSION

This study provides the largest data on biopsy proven renal disease in children from South Asia published till date and highlights important differences in the spectrum and trends of kidney disease compared to data from other regions.

Proteinuric kidney disease in children at Queen Elizabeth Central Hospital, Malawi

BACKGROUND

There is a paucity of data on paediatric kidney disease in developing countries such as Malawi. Descriptive research on kidney disease is essential to improving patient outcomes.

METHODS

We conducted a cross-sectional study at a tertiary hospital in Malawi from 2012 to 2013. Children under 14 years with proteinuric kidney disease were enrolled from paediatric wards and outpatient clinics at Queen Elizabeth Central Hospital (QECH). Demographic, clinical and laboratory data were collected from patients at enrolment and at 3 months review at which point clinical status and disease outcome were ascertained.

RESULTS

Thirty-four (22 male) patients were studied, mean age 8.54 (SD = 3.62 years). Glomerular disease (n = 25, 68%) was the most common presumed renal lesion at presentation. Nephritic syndrome (10) was characterised by a lower baseline complement C3 than nephrotic syndrome (p = 0.0027). Seven (47%) cases of nephrotic syndrome achieved complete remission. Eight (80%) cases of nephritic syndrome improved with supportive therapy. Nineteen (56%) patients presented with clinically significant renal damage with eGFR< 60 ml/min/1.73m². Six patients presented in chronic kidney disease (CKD) stage 5 of unclear aetiology, five (83%) died. Three (9%) patients had impaired kidney function and obstructive uropathy demonstrated on ultrasound, two recovered after surgery and one died. Eight (24%) patients had acute kidney injury (AKI) due to primary kidney disease, three of these patients progressed to CKD stage G3a. Seven (21%) patients were lost to follow up.

CONCLUSION

Kidney disease is a significant cause of mortality and morbidity in children at QECH. Less than half of Nephrotic syndrome cases achieved complete remission. Mortality is highest in children with CKD of unclear cause. Some patients with AKI secondary to primary renal disease progressed to CKD. Understanding the aetiology of paediatric kidney disease and improving patient outcomes by developing enhanced diagnostic and clinical services are priorities at QECH and within Malawi.

Systematic Literature Review on the Incidence and Prevalence of Heart Failure in Children and Adolescents

While the epidemiology of adult heart failure has been extensively researched, this systematic review addresses the less well characterized incidence and prevalence of pediatric HF. The search strategy used Cochrane methodology and identified 83 unique studies for inclusion. Studies were categorized according to whether the HF diagnosis was reported as primary (n = 10); associated with other cardiovascular diseases (CVDs) (n = 49); or associated with non-CVDs (n = 24). A narrative synthesis of the evidence is presented. For primary HF, the incidence ranged from 0.87/100,000 (UK and Ireland) to 7.4/100,000 (Taiwan). A prevalence of 83.3/100,000 was reported in one large population-based study from Spain. HF etiology varied across regions with lower respiratory tract infections and severe anemia predominating in lower income countries, and cardiomyopathies and congenital heart disease major causes in higher income countries. Key findings for the other categories included a prevalence of HF associated with cardiomyopathies ranging from 36.1% (Japan) to 79% (US); associated with congenital heart disease from 8% (Norway) to 82.2% (Nigeria); associated with rheumatic heart diseases from 1.5% (Turkey) to 74% (Zimbabwe); associated with renal disorders from 3.8% (India) to 24.1% (Nigeria); and associated with HIV from 1% (US) to 29.3% (Brazil). To our knowledge, this is the first systematic review of the topic and strengthens current knowledge of pediatric HF epidemiology. Although a large body of research was identified, heterogeneity in study design and diagnostic criteria limited the ability to compare regional data. Standardized definitions of pediatric HF are required to facilitate cross-regional comparisons of epidemiological data.

Acute Kidney Injury in the Tropics: Epidemiology, Presentation, Etiology, Specific Diseases, and Treatment

The characteristics of AKI are significantly influenced by the setting in which it develops. The unique characteristics in the tropical ecosystem along with the prevailing socioeconomic circumstances in the region make AKI in the tropics different regarding etiology, clinical characteristics, and outcomes. Community-acquired AKI caused by infections; animal, plant, or chemical toxins; and obstetric complications are common in the tropics, compared to predominantly hospital-acquired AKI from sepsis and diagnostic and therapeutic interventions elsewhere. It is possible to discern certain distinct “AKI syndromes” in the tropics, like febrile illness with AKI, envenomation-related AKI, and obstetric AKI, where the patients develop AKI along with a typical constellation of clinical features, allowing more specific and quick diagnostic and therapeutic approach. Changes in disease epidemiology and ongoing socioeconomic transitions in the tropics are reflected in changing epidemiology of tropical AKI. While the incidence of obstetric AKI has shown a steady decline, HIV-associated AKI emerged as a significant entity in regions where HIV was endemic in the past few decades. There is better recognition of scrub typhus as a significant contributor to AKI with availability of better diagnostic techniques, and it is well recognized that the epidemiology of AKI associated with post-infectious glomerulonephritis is different in the tropics. Rapid urbanization has made large swaths of population susceptible to emerging infections like dengue fever, with increased incidence of AKI. Climate change and scarcity of potable water are expected to pose significant challenges to kidney health in the tropics in the future. However, community-acquired AKI in the tropics also presents a unique opportunity for prevention of AKI, and attendant morbidity and mortality as most of the contributing factors can be addressed by public health interventions and innovative strategies to deliver healthcare.