Acute Post-Streptococcal Glomerulonephritis in the Northern Territory of Australia: A Review of 16 Years Data and Comparison with the Literature

Abstract

Data relating to acute post-streptococcal glomerulonephritis (APSGN) from the notifiable diseases surveillance system in the Northern Territory of Australia was extracted and analyzed. Isolates of Streptococcus pyogenes from confirmed cases were emm sequence typed. From 1991 to July 2008, there were 415 confirmed cases and 23 probable cases of APSGN notified. Four hundred fifteen (94.7%) of these were Indigenous Australians and 428 (97.7%) were people living in remote or very remote locations. The median age of cases was 7 years (range 0–54). The incidence of confirmed cases was 12.5/100,000 person-years, with an incidence in Indigenous Australian children younger than 15 years of age of 94.3 cases/100,000 person-years. The overall rate ratio of confirmed cases in Indigenous Australians to non-Indigenous Australians was 53.6 (95% confidence interval 32.6–94.8). Outbreaks of disease across multiple communities occurred in 1995 (N = 68), 2000 (N = 55), and 2005 (N = 87 [confirmed cases]). Various emm types of S. pyogenes were isolated from cases of APSGN including some types not previously recognized to be nephritogenic. The widespread outbreak in 2005 was caused by emm55.0 S. pyogenes. Acute post-streptococcal glomerulonephritis continues to occur in remote Indigenous communities in Australia at rates comparable to or higher than those estimated in developing countries. Improvements in preventative and outbreak control strategies are needed.

Renal histology in Indigenous Australians with lupus nephritis

“…Lifetime UV exposure and rates of scabies, Streptococcal, Strongyloides and Mycobacterium infections are higher in northern Australian communities and together could increase LN susceptibility as these have been associated with significantly higher serum levels of immunoglobulins, anti-dsDNA antibody presence and renal mesangial proliferation. [17][18][19] This would be compatible with the intriguing observation that Class II LN (i.e., mesangial proliferation) was more frequently observed in IA patients and further supported by the lower AI score observed in this group. Together this indicates a lower inflammatory renal burden at the time of biopsy in IA patients and suggests that despite a similar prevalence of anti-dsDNA antibodies, much of the increased renal immune deposits in this group of IA patients did not contain nephritogenic auto-antibodies.…”

“…5 The reasons for this increased risk of death and progression to ESRD are likely multifactorial; the majority of our IA cohort belonged to disadvantaged communities, where low socio-economic status, poor compliance and a high prevalence of comorbidity such as arterial hypertension and diabetes mellitus impact on the prognosis. 18,23 The observed survival disparity is not unique to LN as it is also seen in IA patients with cancer or receiving renal replacement therapy. [24][25][26][27] The fact that LN class and renal activity index or serological disease measures were not predictive of renal survival strongly suggests that factors other than histological LN severity contribute to this poor renal prognosis.…”

Disease Manifestations and Pathogenic Mechanisms of Group A Streptococcus

“…Globally, there are over 470,000 annual cases, resulting in approximately 5,000 deaths worldwide (5). APSGN rates are highest in children in less developed countries, with incidence rates as high as 94.3/1,000 being reported in the Northern Territory of Australia (76). Unlike ARF, APSGN tends to occur in outbreaks associated with "nephritogenic" strains of GAS (e.g., emm types 1, 4, 12, 49, 55, 57, and 60) and contributing risk factors such as crowding, poor hygiene, and poverty (75)(76)(77).…”

Staphylococcal and Streptococcal Superantigen Exotoxins

“…There are an estimated 10 million cases of pharyngitis in the United States each year. The organisms can also cause life-threatening illnesses such as TSS with or without necrotizing fasciitis and myositis (19,20), and the organisms are associated with development of autoimmune diseases such as rheumatic fever (21), acute glomerulonephritis (22), and guttate psoriasis (23). Group A streptococci may be asymptomatically carried by up to 10 to 20% of humans, usually after having overt infections (24).…”