Eosinophilic glomerulonephritis in children in Southwestern Uganda

Abstract

Acute renal disease is common in sub-Saharan Africa, with high mortality. Its etiology is poorly understood; quartan malaria owing to Plasmodium malariae was implicated in previous series. Few previous studies have included histological data; furthermore, much of the literature pre-dates the human immunodeficiency virus (HIV) epidemic. We report prospective analysis of acute proteinuric renal disease in children in rural Uganda. Clinical and laboratory data are presented on 65 patients (aged 2-14 years, mean 8.4; 35 male, 30 female) in 41 of whom histological diagnosis was obtained by renal biopsy. The most frequent histological finding was endocapillary proliferative glomerulonephritis (GN) in 27/41 cases, in 20 of which eosinophils were very prominent. No cases showed features of HIV nephropathy. Malarial films were positive in 11 cases: all owing to Plasmodium falciparum. Patients were treated with diuretics, antihypertensives, and supportive measures. Corticosteroids were rarely used, being reserved for patients with minimal changes on renal biopsy. Clinical outcomes were fair: 91% of patients survived to discharge. We conclude that acute GN is common in children in Uganda, that an unusual eosinophilic proliferative GN is the most frequent histological finding, that HIV is not implicated as an important factor in this age group, and that good outcomes can be achieved using simple clinical and laboratory diagnostic methods. Renal biopsy in selected cases is feasible and helpful, especially in allowing rational use of corticosteroids and other potentially toxic treatments. Symptomatic treatments and careful supportive care will allow the majority of children to recover.

Kidney involvement in malaria: an update

“…More recent studies have also found IgA deposits in malaria-associated AKI, with resolution after the acute phase of the infection 21 , 22 , as illustrated in Figure 2 . Eosinophilic glomerulonephritis has also been found in children with P. falciparum infection 23 ( Figure 3 ). Electronic microscopy findings evidence the presence of electron-dense deposits in subendothelial and mesangial region, associated with the presence of granular, fibrilar and amorphous material.…”

“…Reproduced by Walker et al . 23 , with permission. ©2007 Elsevier – The International Society of Nephrology …”

“…The most common glomerular disease associated with P. malariae infection is the membranoproliferative glomerulonephritis. An electron microscopy study has shown the thickening of glomerular capillary walls caused by subendothelial deposits, with “tram track” appearance and mesangial proliferation 23 . Immunofluorescence has shown granular deposits through the endothelium with IgG, IgM, C3 and parasite’s antigens deposits.…”

The Players: Cells Involved in Glomerular Disease

“…Temporally, at least in responding to foreign antigens, Th17 cells act earlier in immune responses and over time convert to a mixed Th1/Th17 or Th1 phenotype (44). Th2 cells support eosinophils, important in allergic interstitial nephritis and in glomerular disease in sub-Saharan Africa (62). CD81 cells are cytotoxic, killing cells that express their cognate peptide with MHC class 1, but also secrete cytokines and may act in a proinflammatory manner (63).…”

Acute kidney injury in Plasmodium vivax malaria hospitalized patients in Manaus, Brazilian Amazon: are we underestimating the real burden?

“…Renal microcirculation blockade due to parasite erythrocytes sequestration play a central role in all aforementioned pathogenic factors of renal failure in falciparum malaria [8,12]. Unlike P. falciparum, P. malariae can cause chronic glomerulopathy that may relentlessly progress to end-stage renal disease, related to granular deposits through the endothelium with IgG, IgM, C3 and parasite antigens deposits [13][14][15].…”