Crescentic Glomerulonephritis Associated with Pulmonary Tuberculosis

Glomerulonephritis during Mycobacterium tuberculosis infection: scoping review

INTRODUCTION

People with Tuberculosis (TB) infection may present with glomerulonephritis (GN). The range of presentations, renal pathologies, and clinical outcomes are uncertain. Whether clinical features that establish if GN etiology is medication or TB related, and possible benefits of immunosuppression remain uncertain.

METHODS

A scoping review was completed, searching MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and Conference Abstracts from Inception to December, 2023. The study population included patients with TB infection who developed GN and underwent renal biopsy. All data regarding presentation, patient characteristics, renal pathology, management of TB and GN, and outcomes were summarized.

RESULTS

There were 62 studies identified, with 130 patients. These cases included a spectrum of presentations including acute kidney injury, nephrotic syndrome and hypertension, and a range of 10 different renal pathology diagnoses. Cases that included immunosuppression and outcomes ranged from complete remission to long-term dialysis dependence. The presence of granulomas (4/4, 100%), anti-glomerular basement membrane disease (3/3, 100%), amyloidosis (75/76, 98.7%), and focal segmental glomerulosclerosis (2/2, 100%) were specific for GN being TB-infection related. On the other hand, minimal change disease was specific for anti-TB therapy related (7/7, 100%). While patients with more aggressive forms of GN commonly were prescribed immunosuppression, this study was unable to confirm efficacy. Only rifampin or isoniazid were implicated in drug-associated GN.

DISCUSSION

This study provides a clear rationale for renal biopsy in patients with TB and GN, and outlines predictors for the GN etiology. Thus, this study establishes key criteria to optimize diagnosis and management of patients with TB and GN.

Mesangiocapillary glomerulonephritis complicating pulmonary tuberculosis

Glomerulonephritis in tuberculosis may be a direct manifestation of renal infection or a result of immune-complex deposition complicating extra-renal infection, such as in pulmonary tuberculosis. A 17-year-old adolescent boy from Somalia was found to have pulmonary tuberculosis during routine health screening performed on entering Malta, with computed tomography of the chest showing scarring and calcification of the left upper lobe, left lower lobe consolidation, and a small left-sided pleural effusion. Five days after starting anti-tuberculous therapy, he developed lower limb and sacral oedema: urinary albumin: creatinine ratio was > 400 µg albumin/mg creatinine, and 24-h urinary protein showed nephrotic-range proteinuria of 4.963 g/day. In view of worsening lower limb, sacral and periorbital oedema and ascites, he was started on oral prednisolone, omeprazole and penicillin V prophylaxis. As heavy proteinuria persisted, a renal biopsy was performed after 8 days of prednisolone treatment, which confirmed the presence of mesangiocapillary glomerulonephritis (MCGN), with electron microscopy showing effacement of the podocytes, with hypercellularity and subendothelial immune deposits, confirming an immune-mediated pathophysiology. Ziehl-Neelsen staining did not reveal acid-fast organisms. The patient received a total of 3 weeks of oral prednisolone with subsequent tailing doses, 2 months of pyrazinamide and ethambutol and 6 months of rifampicin and isoniazid with complete resolution of his clinical and radiological signs, though heavy proteinuria persisted, so he was commenced on oral enalapril. This case highlights the potential association of MCGN with tuberculosis in adolescence. Timely recognition and treatment can prevent progression to chronic kidney disease.