1
|
Bonner RW, Moreno V, Jain K. Infection-Associated Glomerulonephritis. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:246-254. [PMID: 39004464 DOI: 10.1053/j.akdh.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 12/20/2023] [Accepted: 01/02/2024] [Indexed: 07/16/2024]
Abstract
The nephritic syndrome has been associated with a wide variety of infections, spanning many organisms and myriad clinical presentations. Infection-associated glomerulonephritis is challenging to diagnose given the many confounding factors linking kidney injury to infection; however, urine microscopy can assist in identifying abnormal cellular elements suggestive of glomerulonephritis. Kidney biopsy remains the gold standard for diagnosing the underlying pathologic lesion. Treatment of infection-associated glomerulonephritis centers around aggressive and complete treatment of the underlying infectious driver. It is often hard to know exactly when immunosuppression may be required in addition to treating the infection.
Collapse
Affiliation(s)
- Ryan W Bonner
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Vanessa Moreno
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Koyal Jain
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| |
Collapse
|
2
|
John EE, Roy S, Eapen JJ, Karuppusami R, Jose N, Mani SSR, Johny J, Alam R, Yusuf S, Thomas A, Valson AT, David VG, Varughese S, Alexander S. Bacterial infection-related glomerulonephritis in patients with diabetes. Nephrology (Carlton) 2023; 28:597-610. [PMID: 37492933 PMCID: PMC7615861 DOI: 10.1111/nep.14222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/19/2023] [Accepted: 07/09/2023] [Indexed: 07/27/2023]
Abstract
AIM Diabetic patients are prone to infections, thus making them a unique cohort at risk of developing bacterial infection-related glomerulonephritis (IRGN). METHODS In total, 1693 adult diabetic patients underwent kidney biopsy between 2005 and 2021 at our tertiary care hospital in South India. Of these, 121 consecutive cases which met criteria of bacterial IRGN were included in this study. RESULTS The mean age of the cohort was 53.1 ± 10.1 years and 83/121 (68.5%) were males. Majority (98.3%) had type 2 diabetes for a median duration of 6 (IQR, 2-12) years. The most common sites of infection were skin (47/121, 38.8%) and urinary tract (15/121, 12.4%). Fifty percent (58/121) of patients had underlying advanced diabetic kidney disease (DKD). Isolated C3 deposits (without immunoglobulin) occurred in 66/121 (54.5%) patients predominantly in advanced DKD patients. IgA-dominant glomerulonephritis occurred in only 9/121 (7.4%) patients. Short-course oral steroid was given to 86/121 (71.1%) patients. Steroid related dysglycemia and immunosuppression related infections occurred in 9/61 (14.8%) and 16/61 (26.2%) patients respectively. Of the 90 patients with follow up details >3 months, 46 (51.1%) progressed to kidney failure over a median period of 0.5 (IQR, 0-7.2) months. Patients diagnosed in the latter half of our study period (2013-2021) were older, less commonly presented with fever, had more pronounced hypocomplementemia and severe renal histology predominantly with a 'starry sky' immunofluorescence pattern. CONCLUSION Superimposed bacterial IRGN on underlying DKD is associated with poor renal outcomes. Use of short course steroid was associated with significant toxicity.
Collapse
Affiliation(s)
| | - Sanjeet Roy
- Department of Pathology, Christian Medical College, Vellore, India
| | | | - Reka Karuppusami
- Department of Biostatistics, Christian Medical College, Vellore, India
| | - Nisha Jose
- Department of Nephrology, Christian Medical College, Vellore, India
| | | | - Joseph Johny
- Department of Nephrology, Christian Medical College, Vellore, India
| | - Rizwan Alam
- Department of Nephrology, Christian Medical College, Vellore, India
| | - Sabina Yusuf
- Department of Nephrology, Christian Medical College, Vellore, India
| | - Athul Thomas
- Department of Nephrology, Christian Medical College, Vellore, India
| | - Anna T. Valson
- Department of Nephrology, Christian Medical College, Vellore, India
| | | | | | | |
Collapse
|
3
|
Iyengar A, Kamath N, Radhakrishnan J, Estebanez BT. Infection-Related Glomerulonephritis in Children and Adults. Semin Nephrol 2023; 43:151469. [PMID: 38242806 DOI: 10.1016/j.semnephrol.2023.151469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
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.
Collapse
Affiliation(s)
- Arpana Iyengar
- Department of Pediatric Nephrology, St John's Medical College Hospital, Bengaluru, India.
| | - Nivedita Kamath
- Department of Pediatric Nephrology, St John's Medical College Hospital, Bengaluru, India
| | - Jai Radhakrishnan
- Department of Nephrology, Columbia University Medical Center, New York, NY
| | | |
Collapse
|
4
|
Barr B, Harasemiw O, Gibson IW, Tremblay-Savard O, Tangri N. The Development of a Comprehensive Clinicopathologic Registry for Glomerular Diseases Using Natural Language Processing. Can J Kidney Health Dis 2023; 10:20543581231178963. [PMID: 37342151 PMCID: PMC10278432 DOI: 10.1177/20543581231178963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/22/2023] [Indexed: 06/22/2023] Open
Abstract
Background Glomerulonephritis (GN) represents a common cause of chronic kidney disease, and treatment to slow or prevent progression of GN is associated with significant morbidity. Large patient registries have improved the understanding of risk stratification, treatment selection, and definitions of treatment response in GN, but can be resource-intensive, with incomplete patient capture. Objective To describe the creation of a comprehensive clinicopathologic registry for all patients undergoing kidney biopsy in Manitoba, using natural language processing software for data extraction from pathology reports, as well as to describe cohort characteristics and outcomes. Design Retrospective population-based cohort study. Setting Tertiary care center in the province of Manitoba. Patients All patients undergoing a kidney biopsy in the province of Manitoba from 2002 to 2019. Measurements Descriptive statistics are presented for the most common glomerular diseases, along with outcomes of kidney failure and mortality for the individual diseases. Methods Data from native kidney biopsy reports from January 2002 to December 2019 were extracted into a structured database using a natural language processing algorithm employing regular expressions. The pathology database was then linked with population-level clinical, laboratory, and medication data, creating a comprehensive clinicopathologic registry. Kaplan-Meier curves and Cox models were constructed to assess the relationship between type of GN and outcomes of kidney failure and mortality. Results Of 2421 available biopsies, 2103 individuals were linked to administrative data, of which 1292 had a common glomerular disease. The incidence of yearly biopsies increased almost 3-fold over the study period. Among common glomerular diseases, immunoglobulin A (IgA) nephropathy was the most common (28.6%), whereas infection-related GN had the highest proportions of kidney failure (70.3%) and all-cause mortality (42.3%). Predictors of kidney failure included urine albumin-to-creatinine ratio at the time of biopsy (adjusted hazard ratio [HR] = 1.43, 95% confidence interval [CI] = 1.24-1.65), whereas predictors of mortality included age at the time of biopsy (adjusted HR = 1.05, 95% CI = 1.04-1.06) and infection-related GN (adjusted HR = 1.85, 95% CI = 1.14-2.99, compared with the reference category of IgA nephropathy). Limitations Retrospective, single-center study with a relatively small number of biopsies. Conclusions Creation of a comprehensive glomerular diseases registry is feasible and can be facilitated through the use of novel data extraction methods. This registry will facilitate further epidemiological research in GN.
Collapse
Affiliation(s)
- Bryce Barr
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Oksana Harasemiw
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Ian W Gibson
- Department of Pathology, University of Manitoba, Winnipeg, Canada
- Shared Health Services Manitoba, Winnipeg, Canada
| | | | - Navdeep Tangri
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| |
Collapse
|
5
|
Kitamura M, Almaani S, Challa B, Doraiswamy M, Ayoub I, Biederman L, Parikh SV, Molovic-Kokovic A, Benedict J, Mhaskar N, Khitan ZJ, Brodsky SV, Nadasdy T, Satoskar AA. The Diagnostic Conundrum of Glomerular Crescents With IgA Deposits. Kidney Int Rep 2023; 8:507-518. [PMID: 36938067 PMCID: PMC10014387 DOI: 10.1016/j.ekir.2022.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 01/01/2023] Open
Abstract
Introduction Glomerulonephritis (GN) with crescents and IgA deposits in kidney biopsy poses a frequent diagnostic and therapeutic dilemma because of multiple possibilities. Methods Native kidney biopsies showing glomerular IgA deposition and crescents (excluding lupus nephritis) were identified from our biopsy archives between 2010 and 2021. Detailed clinicopathologic features were assessed. One-year clinical follow-up on a subset of cases was obtained. Results A total of 285 cases were identified, and these clustered into IgA nephropathy (IgAN, n = 108), Staphylococcus or other infection-associated GN/infection-related GN (SAGN/IRGN, n = 43), and antineutrophil cytoplasmic antibody-associated GN (ANCA-GN, n = 26) based on a constellation of clinicopathologic features, but 101 cases (group X) could not be definitively differentiated. The reasons have been elucidated, most important being atypical combination of clinicopathologic features and lack of definitive evidence of active infection. Follow-up (on 72/101 cases) revealed that clinicians' working diagnosis was IgAN in 43%, SAGN/IRGN in 22%, ANCA-GN in 28%, and others in 7% of the cases, but treatment approach varied from supportive or antibiotics to immunosuppression in each subgroup. Comparing these cases as "received immunosuppression" versus "non-immunosuppression," only 2 features differed, namely C3-dominant staining, and possibility of recent infection (both higher in the no-immunosuppression group) (P < 0.05). Renal loss was higher in the non-immunosuppression subgroup, but not statistically significant (P = 0.11). Conclusion Diagnostic overlap may remain unresolved in a substantial number of kidney biopsies with glomerular crescents and IgA deposits. A case-by-case approach, appropriate antibiotics if infection is ongoing, and consideration for cautious immunosuppressive treatment for progressive renal dysfunction may be needed for best chance of renal recovery.
Collapse
Affiliation(s)
- Mineaki Kitamura
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Salem Almaani
- Division of Nephrology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bindu Challa
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Isabelle Ayoub
- Division of Nephrology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Laura Biederman
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Samir V. Parikh
- Division of Nephrology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Jason Benedict
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Zeid J. Khitan
- Marshall University School of Medicine, Huntington, West Virginia, USA
| | - Sergey V. Brodsky
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Tibor Nadasdy
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Anjali A. Satoskar
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Correspondence: Anjali A. Satoskar, Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, M015 Starling Loving Hall, 320 West 10th Avenue, Columbus, Ohio 43210, USA.
| |
Collapse
|
6
|
Nagayama Y, Edamoto M, Komine Y, Nakai H, Ichikura-Iida A, Inoue T, Ono K, Otani M, Iwasaki S. Streptococcal Infection-related Glomerulonephritis in an Elderly Diabetic Patient Complicated by Hemophagocytic Syndrome and Cytomegalovirus Nephritis. Intern Med 2023; 62:261-267. [PMID: 35768220 PMCID: PMC9908401 DOI: 10.2169/internalmedicine.9314-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
There has been a significant shift in epidemiology and renal outcomes of infection-related glomerulonephritis (IRGN) in recent years. The renal prognosis of IRGN is often poor in adults, especially in the elderly and diabetics. We herein report an elderly diabetic patient with IRGN due to streptococcal infection complicated by hemophagocytic syndrome and cytomegalovirus nephritis, which is uncommon among non-transplant patients. Infection control and steroids did not recover the patient's renal function. For elderly IRGN patients with diabetes, a further investigation of the most effective treatment for related renal outcomes is needed.
Collapse
Affiliation(s)
| | - Mio Edamoto
- Department of Nephrology, Yokohama Municipal Citizen's Hospital, Japan
| | - Yuna Komine
- Department of Nephrology, Yokohama Municipal Citizen's Hospital, Japan
| | - Hiroki Nakai
- Department of Nephrology, Yokohama Municipal Citizen's Hospital, Japan
| | | | - Takashi Inoue
- Department of Nephrology, Yokohama Municipal Citizen's Hospital, Japan
| | - Kyoko Ono
- Department of Diagnostic Pathology, Yokohama Municipal Citizen's Hospital, Japan
| | - Masako Otani
- Division of Diagnostic Pathology, Yokohama City University Medical Center, Japan
| | - Shigeki Iwasaki
- Department of Nephrology, Yokohama Municipal Citizen's Hospital, Japan
| |
Collapse
|
7
|
John EE, Roy S, Eapen JJ, Alam R, Varughese S. When to Suspect Non-diabetic Kidney Disease in a Diabetic Patient? Cureus 2022; 14:e28091. [PMID: 36158327 PMCID: PMC9484782 DOI: 10.7759/cureus.28091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/29/2022] Open
Abstract
The diagnosis of non-diabetic kidney disease (NDKD) in a diabetic patient has significant therapeutic and prognostic implications. There are certain proven clinical predictors of NDKD, which, when present in an appropriate clinical setting, would warrant a kidney biopsy. Herein, we describe four cases of NDKD diagnosed in rather unusual clinical settings, which add to the list of clinical predictors of NDKD. The first case was a “parainfectious glomerulonephritis” diagnosed in a 50-year-old diabetic woman who presented with persistent renal dysfunction despite successful treatment of urinary tract infection. The second case was “membranous nephropathy” diagnosed in a 43-year-old man with long-standing type 1 diabetes, which was associated with other microvascular complications. In this case, the only predictor was disproportionately low serum albumin. The third case was “amyloid light chain (AL) amyloidosis” diagnosed in an elderly diabetic who presented with progressive anasarca over six months. In this case, the only clinical predictor was a disassociation observed between urine dipstick and 24-hour protein estimation. In the fourth case, an elderly diabetic woman without underlying diabetic retinopathy presented with sudden onset nephrotic syndrome. A kidney biopsy was suggestive of diffuse nodular glomerulosclerosis. Immunofluorescence and electron microscopic evaluation were diagnostic of “gamma heavy chain deposition disease.” In all four cases, diagnosis of NDKD led to major therapeutic changes and attainment of renal remission. We have extensively reviewed all major biopsy cohorts of NDKD and have formulated an approach to the diagnosis of NDKD.
Collapse
|
8
|
Chienwichai K, Chareonlap C, Wetwittayakhlung P, Chetthanukul P, Chang A. Emphysematous Pyelonephritis with IgA-Dominant Infection-Related Glomerulonephritis: An Unusual Picture. Acta Med Acad 2022; 51:59-63. [PMID: 35695404 PMCID: PMC9982857 DOI: 10.5644/ama2006-124.371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 04/24/2022] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE The aim of this case report is to illustrate a very rare case of emphysematous pyelonephritis complicated by IgAdominant postinfectious glomerulonephritis. CASE REPORT We report the case of a 53-year-old woman with emphysematous pyelonephritis who initially presented with unintentional weight loss for 3 months and subnephrotic range proteinuria without fever. Urinalysis revealed proteinuria, microscopic hematuria, and pyuria. A kidney biopsy was performed for suspected glomerulonephritis. The patient's right kidney biopsy was consistent with immunoglobulin A (IgA)-dominant infection-related glomerulonephritis. Abdominal computed tomography to seek the possible source of infection revealed staghorn stones obstructing dilated calyces and gas collection within the collecting system. The final diagnosis was emphysematous pyelonephritis of the left kidney complicated by IgA-dominant infection-related glomerulonephritis of the right kidney. CONCLUSION We present an atypical presentation of emphysematous pyelonephritis in terms of clinical presentation (prolonged course of illness without fever) and its complications (IgA-dominant infection-related glomerulonephritis). This case study highlights the critical role of kidney biopsy in the diagnosis and the diverse clinical manifestations in clinical medicine.
Collapse
Affiliation(s)
- Kittiphan Chienwichai
- Division of Nephrology, Department of Internal Medicine, Hatyai Hospital, Songkhla, Thailand
| | | | | | | | - Arunchai Chang
- Department of Internal Medicine, Hatyai Hospital, Songkhla, Thailand. ORCID ID: https://orcid.org/0000-0002-0158-2685.
| |
Collapse
|
9
|
Medjeral-Thomas NR, Pusey CD. New Insights into Epidemiology and Outcome of Bacterial Infection-Related Glomerulonephritis. Clin J Am Soc Nephrol 2021; 16:1149-1151. [PMID: 34362782 PMCID: PMC8455045 DOI: 10.2215/cjn.07910621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/11/2021] [Accepted: 06/11/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Nicholas R. Medjeral-Thomas
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Charles D. Pusey
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| |
Collapse
|