IgA-dominant Infection-related Glomerulonephritis in India: A Single-center Experience

Short-Term Outcomes of Infection-Related Glomerulonephritis in Diabetes Mellitus

Background and objective Infection-related glomerulonephritis (IRGN) in adults, particularly the diabetic population, has a grave prognosis with many patients progressing to dialysis-dependent renal failure. Indian data on this entity are very scarce. This study attempts to correlate the clinicopathological factors related to diabetic IRGN and its short-term outcomes. Subjects and methods A retrospective analysis of all diabetic patients with biopsy-proven IRGN between January 2017 and August 2021 was conducted. Factors affecting outcomes such as clinical characteristics, urine examination, complete blood count, serum biochemistry, renal biopsy, and follow-up data were obtained and analyzed to determine the risk of progression to chronic kidney disease (CKD)/end-stage renal disease (ESRD). Univariate/multivariate analysis and receiver operating characteristic (ROC) curve were performed to identify independent risk factors affecting outcomes. Results A total of 40 diabetic patients with IRGN was included in the study, with a mean age of 53.08 ± 10 years, comprising predominantly males (60%). Infective foci were occult in majority (37.5%). Isolated low C3 levels were documented in the majority, while three patients (7.5%) had normal complement levels. Complete renal recovery was noted in 15 patients (37.5%), while 12 patients (30%) progressed to ESRD. Anuria or uremia at presentation, glomerulosclerosis >28.6%, interstitial fibrosis with tubular atrophy (IFTA) >17.5%, and diabetic nephropathy correlated to poor renal recovery. No correlation was observed between endocapillary proliferation, the pattern of deposits, the prevalence of crescents, and complement levels with the outcome. Conclusion IRGN is a common immune-mediated clinical entity among diabetics and often requires renal replacement therapy. Anuria or uremia at presentation, diabetic nephropathy, elevated glomerulosclerosis, and IFTA were associated with poor renal recovery. Complement levels and crescents had no impact on the outcome.

The Pulsing Paradox: Successful Steroid Therapy in Infection-Related Glomerulonephritis

The patterns of infection-related glomerulonephritis (IRGN) are rapidly changing in terms of age at presentation and sources of infection. The existing literature on the use of steroids in IRGN is inconsistent. A diabetic male in his sixties presented with features of anasarca, bilateral flank pain, and acute pulmonary edema. He had a non-healing ulcer over his right leg, with pus culture showing growth of methicillin-resistant Staphylococcus aureus (MRSA). Computed tomography (CT) of the kidneys, ureter, and bladder (KUB) showed features of bilateral pyelonephritis. The patient went on to develop acute renal failure and eventually required hemodialysis. A renal biopsy was performed, and features of IRGN with crescents were noted. Considering the presence of crescents in renal biopsy, a trial of steroids was given under antibiotic cover, which resulted in a near-complete resolution of renal failure.

Infection-Related Glomerulonephritis in Children and Adults

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.

Clinical Profile, Histopathology, and Outcomes in Infection-Related Glomerulonephritis - Single-Center Experience

Background

Infection-related glomerulonephritis (IRGN) is an important source of renal morbidity with adverse outcomes in adults. Data from large centers in India is lacking on this common, yet poorly understood entity.

Materials and Methods

We performed a prospective observational study of all patients diagnosed with IRGN at our center over a 3-year period between 2017 and 2019. "Typical IRGN" patients were diagnosed based on clinical and laboratory assessment; others underwent renal biopsy. Renal and patient survival outcomes were assessed in addition to factors that help predict outcomes.

Results

One hundred and twenty-five patients with a diagnosis of IRGN were included in the study, including 86 patients who underwent renal biopsy. This represented 24% of all biopsies during this time period, and IRGN was the most common nondiabetic kidney disease identified in diabetic biopsies at our center. Female preponderance and a seasonal variation were striking. Atypical sources of infection like otomycosis, tooth abscess, and dengue virus infection were noted. Male gender and diabetes were important risk factors for severe disease. Rapidly progressive glomerulonephritis (RPGN), atypical serum complement profiles, and comorbid illnesses were common in adults. Though children had more benign disease and outcomes, life-threatening complications were also noted. C3 dominance was the most striking immunofluorescence (IF) finding and was associated with poorer outcomes. Crescentic IRGN was rare, and four cases of IgA-dominant IRGN were noted. Also, 24% of the cohort required renal replacement therapy. RPGN presentation of IRGN portended worst prognosis with end-stage renal disease (ESRD) in 31% and death in 22% of patients.

Conclusion

IRGN is a common clinical entity in adults with the potential for adverse renal and survival outcomes. We have identified clinical and biopsy characteristics that are associated with ESRD and death.

Efficacy of Corticosteroids in Infection-Related Glomerulonephritis–A Randomized Controlled Trial

Introduction

Infection-related glomerulonephritis (IRGN) is associated with glomerular immune complex deposition along with complement activation. Steroids may attenuate glomerular injury and thereby improve renal outcomes.

Methods

We randomly assigned patients who had biopsy-proven IRGN and serum creatinine greater than 1.5 mg/dl to receive corticosteroids plus supportive care (intervention arm), or supportive care alone (control arm). Patients were followed up for 6 months. The primary outcome was complete renal recovery at 6 months. Safety of steroid therapy was also assessed.

Results

A total of 52 patients underwent randomization. At 6 months, 17 of 26 patients (65.4%) in the intervention arm and 14 of 26 patients (53.8%) in the control arm had complete renal recovery (odds ratio 1.6; 95% confidence interval, 0.5–4.9; P = 0.397). There was no statistically significant difference in any of the secondary outcomes. Adverse events occurred in 12 patients (46.2%) in the intervention arm and 2 patients (7.7%) in the control arm (P = 0.002).

Conclusion

In this single-center trial, corticosteroids did not result in a statistically significant increase in rates of complete renal recovery at 6 months. There was a significantly increased risk of adverse events associated with the use of corticosteroids.

Staphylococcus aureus Infection-Related Glomerulonephritis with Dominant IgA Deposition

Since 1995, when we reported the case of a patient with glomerulonephritis with IgA deposition that occurred after a methicillin-resistant Staphylococcus aureus (MRSA) infection, many reports of MRSA infection-associated glomerulonephritis have accumulated. This disease is being systematized as Staphylococcus infection-associated glomerulonephritis (SAGN) in light of the apparent cause of infection, and as immunoglobulin A-dominant deposition infection-related glomerulonephritis (IgA-IRGN) in light of its histopathology. This glomerulonephritis usually presents as rapidly progressive glomerulonephritis or acute kidney injury with various degrees of proteinuria and microscopic hematuria along with an ongoing infection. Its renal pathology has shown several types of mesangial and/or endocapillary proliferative glomerulonephritis with various degrees of crescent formation and tubulointerstitial nephritis. IgA, IgG, and C₃ staining in the mesangium and along the glomerular capillary walls have been observed on immunofluorescence examinations. A marked activation of T cells, an increase in specific variable regions of the T-cell receptor β-chain-positive cells, hypercytokinemia, and increased polyclonal immune complexes have also been observed in this glomerulonephritis. In the development of this disease, staphylococcal enterotoxin may be involved as a superantigen, but further investigations are needed to clarify the mechanisms underlying this disease. Here, we review 336 cases of IgA-IRGN and 218 cases of SAGN.

Indian scenario of IgA nephropathy: a systematic review and meta-analysis

BACKGROUND

IgA nephropathy (IgAN) is most common primary glomerulopathy. There are variations in prevalence of IgAN and its clinical features in different studies from India.

AIM

To summarize overall scenario of IgAN in India.

METHODS

In this systematic review, studies related to IgAN and related renal disease were included. Data searched were PubMed, EMBASE, Google scholar, and Cochrane Database from inception to 31st January 2019.

RESULTS

Total 49 studies (N=2480) were included: 21 studies (N=2309) of primary IgAN; 19 studies (N=21) of Secondary IgAN; four studies (N=133) of IgA vasculitis nephropathy (IgAVN); and five studies (N=17) of IgA dominant nephropathy (IgADN). Prevalence of IgAN was 16.5% in India. Age of affected persons was ranging from 27.2±16.7 to 48.6±21.3 years . Male female ratio was 1.8:1. Clinical features of Primary IgAN, IgAVN, IgADN & Secondary IgAN were microscopic hematuria (49.6%, 44.4%, 15.6% & 59.5%), macroscopic hematuria (5.1%, 0.4%,40.9%,& 35.7%), Subnephrotic proteinuria (42.1%, 29.4%, 23.2%, & 52.3%), nephrotic proteinuria (16.0%, 4.4%, 76.8%,& 47.6%), and hypertension (25.8%,18.3%, 35.5%,& 47.6%).. The 24 hours proteinuria was ranging from 2.6±1.5 to 4.7±2.3 gm/day and serum creatinine (mg/dl) was ranging from 0.9±0 to 3.5±3.9 mg/dl. Histolomorphologically, all type of IgAN showed mesangial hypercellularity and Immunofluorescence revealed IgA deposition..

CONCLUSION

The overall prevalence of primary IgAN in India was 16.5%. The subnephrotic proteinuria and microscopic hematuria were common clinical features.

A Case Report of Generalized Pustular Psoriasis Associated With IgA Nephropathy

Psoriasis vulgaris is a complex immune-mediated disorder that manifests as a chronic skin disorder, characterized by well-circumscribed inflammatory, erythematous plaques. In this case report, we present a patient with generalized pustular psoriasis (GPP) who presented to the nephrology department with rapidly progressive decline in renal function. The diagnosis of GPP was made a month ago, secondary to a coagulase-negative staphylococcal superinfection. Intrinsically, this introduced a diagnostic challenge as the presumed diagnosis of immunoglobulin A (IgA) nephropathy had to be distinguished from IgA-dominant infection-related glomerulonephritis. We further discuss the current evidence and immunohistological profiles of IgA nephropathy in psoriasis and detail the evolution of renal function of our patient over 25 months after he presented to our department.