The Current Spectrum of Infectious Glomerulonephritis: Experience with 76 Patients and Review of the Literature

Abstract

To identify the demographic, clinical, and pathologic features and the prognosis of renal disease in a series of patients with infectious or postinfectious proliferative glomerulonephritis (GN), data were collected from records of 76 adult patients admitted from 1976 to 1993 to 2 neighboring suburban hospital nephrology units, whose catchment population consists of patients living in a suburban borough of Paris with a below-average socioeconomic status. Thirty-four patients (45%) were alcoholics, diabetics, or intravenous illicit-drug users. Sixty-six patients presented with acute nephritic and/or nephrotic syndrome. Acute renal failure was present in 56 (76%) and required dialysis in 14. The diagnostic workup comprised at least 1 renal biopsy in each case. The patient's background, site of infection, clinical course, laboratory variables, and, when available, bacteriologic findings were analyzed in each case to interpret the evolution of the disease. Initial renal biopsy disclosed endocapillary GN in 44 patients, crescentic GN in 26, and membranoproliferative GN in 6. Ten patients had endocarditis. Staphylococci and Gram-negative strains, not streptococci, were the most common bacteria identified. The origin of sepsis was mainly the oropharynx (21), the skin (19) and the lung (14); 19 cases involved multiple sites of infection. Eight patients died (11%), and 20 (26%) recovered renal function, but GN followed a chronic course in 38 (50%), rapidly requiring maintenance dialysis in 6. Poor prognostic factors included age over 50 years, purpura, endocarditis, and glomerular extracapillary proliferation. Twenty-six patients underwent repeat renal biopsy 1 month to 11 years after the initial presentation. The main finding, irrespective of the interval since the first biopsy, was that ongoing or new iatrogenic infection acquired during hospitalization was almost invariably acquired during hospitalization was almost invariably associated with developing glomerular proliferative changes. This study shows that infectious proliferative GN remains common, but that its epidemiology has changed from what was observed until 2 decades ago. The responsible bacteria, when identified, now comprise a majority of staphylococci and Gram-negative strains, in contrast to the streptococci which predominated 3 decades ago. Infectious GN affects with increasing frequency patients with an underlying condition responsible for immunosuppression, especially alcoholism, even in the absence of cirrhosis. Destructive glomerular proliferation persists, especially but not exclusively until infection has been eradicated, and despite rescue treatment with corticosteroids and/or cytostatic drugs. Thus, the prognosis is poor, and infectious GN often ends in renal death. Infection continues in this decade to represent a frequent and probably often overlooked cause of end-stage renal failure.(ABSTRACT TRUNCATED AT 400 WORDS)

The Current State of Poststreptococcal Glomerulonephritis

“…5 Despite the reduction in worldwide incidence of PSGN, epidemics and clusters of cases of PSGN continue to appear. Table 1 lists epidemics with Ͼ100 cases 10,[15][16][17][18][19][20][21][22][23][24] and Table 2 the epidemics with Ͻ100 cases or clusters in families or communities.…”

“…Acute postinfectious glomerulonephritis is frequently the cause of severe acute renal failure (requiring dialysis and/or admission to pediatric intensive care units) in underdeveloped countries. The proportion of cases of acute renal failure that correspond to acute postinfectious glomerulonephritis of demonstrated or assumed poststreptococcal etiology is 13% in New Delhi, 44 30% in Istanbul, 45 51.6% in Casablanca, 46 4.6% in Lagos, 47 27% in Bombay, 48 19.2% in Lucknow, 49 33% in Asunció n, 50 17.4% in Chandrigarth, 51 5.2% in Lima, 52 9.3% in Varanasi, 53 and 25% in Osun State, Nigeria. 54 …”

American Society of Nephrology Quiz and Questionnaire 2012

“…The lag time between the start of the infection and the clinical manifestations can vary from a few days to weeks, and disease severity ranges from asymptomatic hematuria to an acute nephritic syndrome, renal failure, and fluid overload. On renal biopsy, postinfectious GN is characterized by proliferative GN on light microscopy, mesangial and/or capillary wall bright C3 staining with or without immunoglobulin on immunofluorescence microscopy, and subepithelial hump-like deposits on electron microscopy (4,5). In some cases, there is no clinical or serologic evidence of a preceding infection, and the diagnosis of postinfectious GN is based solely on these renal biopsy findings.…”

“…In some cases, there is no clinical or serologic evidence of a preceding infection, and the diagnosis of postinfectious GN is based solely on these renal biopsy findings. It should be also recognized that over the past 30 years, an important shift in epidemiology, bacteriology, and outcome of GN related to infection has occurred (5). A substantial number of cases now occur in adults, particularly the elderly, alcoholic persons, and patients who are immunocompromised.…”

A Rare Clinical Entity: Staphylococcus-Related Glomerulonephritis

“…Treatment of the disease in adults should focus on eradicating the infection, relieving symptoms, and controlling hypertension and edema. [1][2][3][4][5] Here, we describe an episode of biopsy-proven diffuse proliferative glomerulonephritis occurring after osteomyelitis.…”