Edit concept Question Editor Create issue ticket

Post-Infectious Glomerulonephritis

Post Infectious Gn

Post-infectious glomerulonephritis is a type of glomerulonephritis, and thus an important cause of nephritic syndrome. It predominantly occurs in children and is a sequela of streptococcal throat or skin infections. The implicated organism is almost always, group A streptococcus.


Presentation

Children older than 3 years are the most susceptible to post-infectious glomerulonephritis (PIGN), with boys affected twice as much as girls. A history of throat infection, tonsillitis or strep throat, for example, about 1 to 2 weeks prior to presentation, or up to 6 weeks in the case of suppurative skin infections such as impetigo, is always present. Only nephritogenic variants of group A streptococcus (GAS) can lead to PIGN [1]. Patients may not always have a record of treatment, as symptoms may have been mild, or resolved quickly, not warranting a hospital visit. Non-specific symptoms seen include tiredness, gastrointestinal upset (nausea, vomiting, abdominal pain), loss of appetite and malaise. Fever is not a common finding and its presence should alert the clinician of ongoing infection.

The usual presenting complaints are some or all of the symptoms characterizing nephritic syndrome namely gross hematuria often described as cola or tea colored urine, microscopic hematuria, hypertension, periorbital edema, and markedly decreased urine output. In some patients, the only sign of the disease is microscopic hematuria; in endemic areas, this alone should raise the suspicion of PIGN [2].

Hypertension and fluid overload can lead to further morbidity; acute confusion, lethargy, seizures, shortness of breath and coughing with or without hemoptysis are amongst the findings [3] [4]. These may indicate the presence of encephalopathy, heart failure or pulmonary-renal syndrome [5]. Other complications include uremia, thrombotic microangiopathy, and nephrotic syndrome after PIGN has been adequately treated [6]. Complications such as these are considerably more frequent in adults than in children. The elderly, diabetics and alcoholics are at an increased risk of developing PIGN.

Rapidly Progressive Glomerulonephritis
  • 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.[ncbi.nlm.nih.gov]
  • At presentation, 89.2% had nephritic syndrome and 9.4% had rapidly progressive glomerulonephritis. Proteinuria was observed in 99.3%, hematuria in 95.3%, peripheral edema in 89.2% and hypertension in 81.8%.[ncbi.nlm.nih.gov]
  • 抄録 A 55-year-old man developed rapidly progressive glomerulonephritis and nephrotic syndrome.[jstage.jst.go.jp]
  • progressive glomerulonephritis, 1 - 2% develop chronic glomerulonephritis Poor prognosis more likely if massive proteinuria and abnormal GFR; 2 - 5% die from pulmonary edema, hypertensive encephalopathy or crescentic glomerulonephritis; children with[pathologyoutlines.com]
  • This lesion, which usually corresponds to rapidly progressive glomerulonephritis, has several aetiologies 18 ; of these, APGN is a rare one, at least in children . 12 13 19 20 Out of 30 patients with crescentic glomerulonephritis in London, only two had[adc.bmj.com]
Steatorrhea
  • الصفحة 157 - Poley, JR: Role of bile acid malabsorption in pathogenesis of diarrhea and steatorrhea in patients with ileal resection. I. Response to cholestyramine or replacement of dietary long chain triglyceride by medium chain triglyceride. ‏[books.google.com]
Dark Urine
  • Symptoms include hypertension, headache, edema, oliguria, dark urine, reduced urine output, flank pain, weight gain, fever, chills, nausea, and vomiting; about half of cases are asymptomatic. Diagnosis is made through a series of lab tests.[medical-dictionary.thefreedictionary.com]
  • The damage may cause dark urine, swelling, high blood pressure, or even kidney failure. Some patients get kidney damage from strep, but it is so mild they never know. Other infections can cause GN, although less commonly than strep.[pascalelane.wordpress.com]
  • urine, typical of the condition, may not be noticed by children.[bpac.org.nz]
  • Symptoms include: pink or dark urine due to blood in your urine (hematuria) foamy urine due to too much protein (proteinuria) high blood pressure fluid retention fatigue kidney failure PANDAS PANDAS stands for Pediatric Autoimmune Neuropsychiatric Disorders[healthline.com]
Smoky Urine
  • Patients with overt disease demonstrate gross hematuria characterized by red or smoky urine, headache, and generalized symptoms such as anorexia, nausea, vomiting, and malaise. 32 Swelling of the renal capsule can cause flank or back pain.[aafp.org]

Workup

A family history of PIGN, especially among siblings, should be inquired about, as this increases the likelihood of the diagnosis by at least 10% [2]. A preceding streptococcal infection is imperative to the diagnosis of PIGN; this might be evident in the patient history. However, in cases where it is unclear, the following laboratory tests are carried out, as they provide evidence of said infection:

  • Serum titers of antistreptolysin O and anti-DNAse will be elevated and have a high detection rate for recent streptococcal infection. The streptozyme test is even more sensitive, as it detects levels of the aforementioned antibodies and, in addition, antihyaluronidase, anti nicotinamide adenine dinucleotidase and antistreptokinase [7].
  • Serum complement levels are usually low, especially complement component 3 (C3).
  • Other tests can also be ordered, including more specialized immune response proteins and autoantibodies such as rheumatic factor [7] [8].

Testing for renal functions may reveal elevated levels of urea and creatinine. Urinalysis is particularly useful and may show white blood cells, microscopic hematuria, red cell casts, epithelial cells as well as hyaline casts. Proteinuria is rarely present, and even when present, it is rarely in the nephrotic range. Imaging studies have no role in diagnosing or treating PIGN. Moreover, renal biopsy is not usually needed and is only done if an alternative diagnosis is suggested by unusual symptoms.

Burr Cell
  • Laboratory evaluation revealed micro-angiopathic anaemia with burr cells, thrombocytopenia, elevated lactic dehydrogenase and low complement C3. Urinalysis showed marked proteinuria and haematuria.[ncbi.nlm.nih.gov]

Treatment

  • Paradoxically, the treatment of glomerulonephritis has become even more complicated in the recent years, after the introduction of a number of newer immunosuppressive drugs.[books.google.com]
  • Antibiotic treatment was administered with improved respiratory symptoms, but worsening renal function.[revistanefrologia.com]
  • […] of antiviral treatment.[panafrican-med-journal.com]
  • In most cases, PIGN is self-limiting and the evidence base for the treatments used is quite weak.[ncbi.nlm.nih.gov]
  • Prevention is also key and involves encouraging individuals to seek early diagnosis and treatment of sore throats and skin lesions, particularly in children.[medical-dictionary.thefreedictionary.com]

Prognosis

  • It is widely recognized that the prognosis of APIGN is good in children. There is however little information about its long-term prognosis in adults.[ncbi.nlm.nih.gov]
  • Regarding the prognosis, the renal death rates of both the SARN and HCVGN groups were significantly higher than those of other PIGN.[ncbi.nlm.nih.gov]
  • Other variables including sex, age, race and the presence or absence of hypertension during the acute phase did not appear in this model to have an important bearing on prognosis, whether the latter was determined by patient and renal survival or by the[ncbi.nlm.nih.gov]
  • In the present study the authors found ESRD in only 14.3% (4 out of 28 cases) that reflects the excellent prognosis of post-infectious glomerulonephritis. Of interest, all of the ESRD patients were caused by post non-Streptococcal GN.[ncbi.nlm.nih.gov]
  • The prognosis is generally excellent, although long-term follow-up may be needed.[ncbi.nlm.nih.gov]

Etiology

  • PSGN was the most common etiology [65(90.3 %)] among the PIGN cases. Pyodermas, upper respiratory infections and varicella preceded hematuria in 58 (80.6 %), 4 (5.6 %) and 2 (2.8 %) cases respectively.[ncbi.nlm.nih.gov]
  • Etiology Postinfectious glomerulonephritis (PIGN), a nephritic syndrome , is the most common cause of a glomerular disorder in children between 5 and 15 yr; it is rare in children 2 yr and uncommon in adults 40 yr.[merckmanuals.com]
  • Epidemiology and Etiology Typical age is 2-12 years. Patients usually have streptococcal pharyngitis or impetigo 5-21 days before PSAGN manifestation.[wikilectures.eu]
  • Etiology/Pathogenesis Poststreptococcal nephritis is an immunologically mediated disease, in which both humoral and cellular immune mechanisms seem to play a role.[barnardhealth.us]
  • .; licensee BioMed Central Ltd. 2014 Received: 22 February 2014 Accepted: 10 September 2014 Published: 13 September 2014 Abstract Background Posterior reversible encephalopathy syndrome is a clinical radiographic syndrome of heterogeneous etiologies.[bmcresnotes.biomedcentral.com]

Epidemiology

  • The aim of this study was to evaluate the epidemiological, clinical and biologic features of APIGN in a Tunisian center.[ncbi.nlm.nih.gov]
  • We studied the epidemiology and clinical spectrum of PIGN in adults to identify the clinical, biochemical and histological factors that would predict renal outcome.[ncbi.nlm.nih.gov]
  • As a result, recent epidemiological data from industrialized countries are scarce. OBJECTIVES: To evaluate patterns of PIGN in children and detect possible predictors of disease severity.[ncbi.nlm.nih.gov]
  • This Review focuses on acute postinfectious glomerulonephritis, and covers its epidemiology, presentation, pathology, pathogenesis, treatment and outcomes.[nature.com]
  • During the past 3 decades although, a major shift has occurred in the epidemiology, characteristics, and outcomes of this disease.[dovepress.com]
Sex distribution
Age distribution

Pathophysiology

  • Definition / general Also called post streptococcal or acute glomerulonephritis; a type of diffuse endocapillary proliferative glomerulonephritis Pathophysiology Deposition of immune complexes from antibodies against organisms elicits acute inflammatory[pathologyoutlines.com]
  • [ edit ] The pathophysiology of this disorder is consistent with an immune -complex-mediated mechanism, a type III hypersensitivity reaction.[en.wikipedia.org]
  • Pathophysiology There are some antigenes produced by Streptococcus pyogenes the most important is NSAP-streptokinase (nephritogen strains associated protein), M-protein and endostreptosin. These antigenes are binded by specific antibodies.[wikilectures.eu]
  • , and Clinical Features Acute Tubular Necrosis: Histopathological Findings Overview of Nephrotic Syndrome: Pathophysiology Overview of Nephrotic Syndrome: Causes Overview of Nephrotic Syndrome: Presentation and Diagnosis Minimal Change Disease: Causes[euro-libris.ro]
  • PIGN is generally a self-limiting form of glomerulonephritis with activation of the alternative complement pathway as the main pathophysiological background.[karger.com]

Prevention

  • Prevention is also key and involves encouraging individuals to seek early diagnosis and treatment of sore throats and skin lesions, particularly in children.[medical-dictionary.thefreedictionary.com]
  • Regular follow-up and monitoring of blood pressure, renal function test, and urine for hematuria and proteinuria every 3-6 months after the acute phase for at least a year is recommended to prevent progression to chronic renal failure. [27] Prevention[ijhas.in]
  • C3NeF is an IgG autoantibody that directly stabilizes the C3-activating complex of the alternative pathway, thus preventing the normal inhibitory action of complement factor H.[karger.com]
  • Antibiotics Help Prevent Spreading the Infection to Others Prevent spreading group A strep infections to others.[cdc.gov]
  • Antimicrobial therapy is preventive only when given within 36 h of infection and before GN becomes established. Key Points Consider PIGN in young patients who have had pharyngitis or impetigo plus signs of GN.[merckmanuals.com]

References

Article

  1. Rodríguez-Iturbe B, Batsford S. Pathogenesis of poststreptococcal glomerulonephritis a century after Clemens von Pirquet. Kidney Int. 2007;71(11):1094–1104.
  2. Rodríguez-Iturbe B, Katiyar VN, Coello J. Neuraminidase activity and free sialic acid levels in the serum of patients with acute poststreptococcal glomerulonephritis. The N Engl J Med. 1981;304(25):1506–1510
  3. Adikari M, Priyangika D, Marasingha I, et al. Post-streptococcal glomerulonephritis leading to posterior reversible encephalopathy syndrome: a case report. BMC Res Notes. 2014;7:644.
  4. Zaki SA, Shanbag P. Unusual presentation of poststreptococcal glomerulonephritis as posterior reversible encephalopathy syndrome. J Pediatr Neurosci. 2014;9(1):42-44.
  5. Mara-Koosham G, Stoltze K, Aday J, Rendon P. Pulmonary Renal Syndrome After Streptococcal Pharyngitis: A Case Report. J Investig Med High Impact Case Rep. 2016 Apr-Jun. 4 (2):2324709616646127.
  6. Kakajiwala A, Bhatti T, Kaplan BS, et al. Post-streptococcal glomerulonephritis associated with atypical hemolytic uremic syndrome: to treat or not to treat with eculizumab?. Clin Kidney J. 2016;9(1):90-96.
  7. Rodríguez-Iturbe B. Epidemic poststreptococcal glomerulonephritis. Kidney Int. 1984;25(1):129–136.
  8. Parra G, Rodriguez-Iturbe B, Batsford S, et al. Antibody to streptococcal zymogen in the serum of patients with acute glomerulonephritis: a multicentric study. Kidney Int. 1998;54(2):509-517.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-21 17:45