Acute Postinfectious Glomerulonephritis Research Articles

Acute Post-infectious Glomerulonephritis in Children Admitted to a Tertiary Care Hospital: A Descriptive Cross-sectional Study

Introduction: Post infectious glomerulonephritis remains the most common cause leading to the majority of hospital admissions in children of developing countries like ours. The aim of ourstudy was to find the prevalence of post infectious glomerulonephritis, study the clinical profile, biochemical changes and its complication in children admitted in a tertiary care hospital of Nepal. Methods: This descriptive cross-sectional study of children admitted at a tertiary care hospital was done from May 2020 till May 2023. A census sampling method was used and sample of 1554 children was taken. Detailed socio demographic data, clinical findings and laboratory investigations were done. Data analysis was done using SPSS software and the results obtained are shown in the form of frequencies along with percentages. Results: Among 1554 patients, the prevalence of acute post-infectious glomerulonephritis was found to be 63 (4.05%) (3.07-5.03 at 95% Confidence Interval). The mean age of the patients was 9.06±3.48 years. Antistreptolysin O titer was raised in 34 (54%) patients, while low serum C3 was observed in 39 (61.90%) patients with acute post-infectious glomerulonephritis. Conclusions: Acute post-infectious glomerulonephritis (APIGN) remains a notable health concern in children, particularly in developing countries like Nepal. This highlights the need for ongoing surveillance, prevention strategies, and effective management protocols to address this burden effectively.

Clinical pattern and outcome of hematuria in children – A prospective follow-up study from South India

Background: Hematuria is defined by the presence of an increased number of red blood cells (RBCs) in the urine. It can be visible or apparent only on microscopic analysis of urine which many times is an incidental finding. The prevalence of microscopic hematuria is 4–5% in routine clinical practice in children of 6–12 years of age. The pediatrician is the first person who comes in contact with children having microscopic or gross hematuria. Updated knowledge of clinical patterns and their outcomes will help improve the management of children with hematuria. Aim and Objective: The aim and objectives are to study the outcome of hematuria in children attending SAT Hospital, Government Medical College, Thiruvananthapuram. Materials and Methods: This is a prospective follow-up study of 100 children admitted with hematuria in our hospital whose ages were between 1 month and 12 years. A preformed and piloted questionnaire was used. Clinical history and examinations were done. Relevant investigations and follow-up assessments were done for 1 year. Biopsy was done for 35 patients by an experienced pediatric nephrologist. Results: Among the 100 children presented with hematuria, 24 had prior renal disease whereas 76 children did not have any pre-existing renal disease. Both were followed up for 1 year. 80% (45) of those without prior renal involvement cleared of hematuria by 1 year and 20% had persistent renal impairment. In the other group with prior renal problems, 75% (15) showed persistent renal problems. School-going children (57%) were mostly affected with female preponderance (30%). The most common etiology was acute post-infectious glomerulonephritis (60%), and the next most common seems to be IgA nephropathy (23%) followed by SLE (17%) Conclusion: Eighty percent of hematuria was found to be resolved completely after 1 year. The remaining 20% has to be carefully evaluated including renal biopsy when indicated. This will help the clinician to provide better care for sick babies with hematuria.

Glomerulonefritis aguda posinfecciosa causada por virus de la gripe B y entero rinovirus

Acute post-infectious glomerulonephritis (APIGN) is an inflammatory lesion with main involvement of the glomerulus triggered by an extrarenal infection. Its pathogenesis is immune, triggered by a wide variety of germs: bacteria, viruses and fungi. The most common cause is poststreptococcal glomerulonephritis (PSAGN). The case that we present was caused by influenza B and enterovirus, etiological agents of infrequent presentation, with clinical manifestations similar to post-streptococcal glomerulonephritis. We conclude that, when faced with a nephritic syndrome clinic, the viral history should be taken into account to make an early diagnosis.

Coexistence of cryoglobulinemia and ANCA-associated vasculitis in a chronic brucellosis patient -a case report and literature review

BackgroundThe renal involvement of brucellosis is not common. Here we reported a rare case of chronic brucellosis accompanied by nephritic syndrome, acute kidney injury, the coexistence of cryoglobulinemia and antineutrophil cytoplasmic autoantibodies (ANCA) associated vasculitis (AAV) superimposed on iliac aortic stent implantation. The diagnosis and treatment of the case are instructive.Case presentationA 49-year-old man with hypertension and iliac aortic stent implantation was admitted for unexplained renal failure with signs of nephritic syndrome, congestive heart failure, moderate anemia and livedoid change in the left sole with pain. His past history included chronic brucellosis and he just underwent the recurrence and completed the 6 weeks of antibiotics treatment. He demonstrated positive cytoplasmic/proteinase 3 ANCA, mixed type cryoglobulinemia and decreased C3. The kidney biopsy revealed endocapillary proliferative glomerulonephritis with a small amount of crescent formation. Immunofluorescence staining revealed only C3-positive staining. In accordance with clinical and laboratory findings, post-infective acute glomerulonephritis superimposed with AAV was diagnosed. The patient was treated with corticosteroids and antibiotics and sustained alleviation of renal function and brucellosis was achieved during the course of a 3-month follow-up.ConclusionsHere we describe the diagnostic and treatment challenge in a patient with chronic brucellosis related glomerulonephritis accompanied by the coexistence of AAV and cryoglobulinemia. Renal biopsy confirmed the diagnosis of postinfectious acute glomerulonephritis overlapping with ANCA related crescentic glomerulonephritis, which was not ever reported in the literature. The patient showed a good response to steroid treatment which indicated the immunity-induced kidney injury. Meanwhile, it is essential to recognize and actively treat the coexisting brucellosis even when there are no clinical signs of the active stage of infection. This is the critical point for a salutary patient outcome for brucellosis associated renal complications.

Glomerulonefritis agudas y rápidamente progresivas, glomerulonefritis proliferativa endocapilar y glomerulonefritis proliferativa extracapilar

Acute (post-infectious) glomerulonephritis presents rapidly with hematuria (microscopic or causes), proteinuria, a decrease in glomerular filtration rate, and sodium and water retention that usually cause an increase in blood pressure and edema. In addition, various types of chronic glomerulonephritis may present as acute nephrotic syndrome and can be clinically indistinguishable from the onset of acute abnormalities. Rapidly progressive glomerulonephritis (RPGN) represents a clinical-pathological syndrome characterized by a rapid decline in renal function (weeks to months); proteinuria generally in a subnephrotic range; and the presence of fibrous, cellular crescents in the glomerular area. Its causes can be primary or secondary. Its classification depends on clinical, serological, and histological findings; they are divided into 3 types: 1, associated with anti-glomerular basement membrane antibodies; 2, associated with immune complexes; 3 pauci-immune (ANCA-associated), or 4, a combination of types 1 and 3. Diagnosis and treatment must be early. High-dose immunosuppressants and, sometimes, plasmapheresis can be used for the purpose of restoring renal function and avoiding rapid progression to advanced or end-stage chronic kidney disease. In cases with very high clinical suspicion, performing a renal biopsy must not delay starting immunosuppressive therapy.

Glomerulonephritis in Children: Epidemiological, Clinical, Paraclinical and Therapeutic Profile

Background: Glomerulonephritis (GN) is a rare kidney disease that causes significant morbidity and mortality. They are frequently difficult to treat, and in some cases, no treatment is available, and they can progress to chronic kidney disease (CKD) and end stage renal disease (ESKD). Kidney biopsy is the preferred diagnostic method because it helps determine the precise specific diagnosis, assesses the level of disease activity and severity, and thus aids in proper therapy and prognosis prediction. Methods: Retrospective review of 40 children under the age of 15 with GN diagnosed between 2019 and 2022. Nephrotic syndrome, sub-nephrotic proteinuria, nephrotic syndrome (NS) with acute kidney injury (AKI), subnephrotic proteinuria plus AKI, isolated hematuria, and unexplained renal impairment were the six clinical syndromes for which a kidney biopsy was performed in 25 patients. Hospital admission records, progression notes, and outpatient follow up were used to collect data. Results: Acute glomerulonephritis (AGN) with nephritic syndrome (NS) affected 53% of the patients. Patients with AGN-NS were more likely to develop hypertension (48.0% vs. 15.7%) and acute renal damage (32% vs. 10%). 48% of the patients had Acute Postinfectious Glomerulonephritis. 5% of the patients had membranoproliferative glomerulonephritis. 2.5% of patients with ANCA-negative rapidly progressive glomerulonephritis had extramembranous glomerulonephritis, and 2.5% had extracapillary glomerulonephritis. The kidneys of 24 people were biopsied. The most common reason for a kidney biopsy was rapidly progressing glomerulonephritis. Conclusion: Acute postinfectious glomerulonephritis has been the most common glomerulonephritis in our study over the last three years in our Marrakech department. It manifested as a rapidly progressive glomerulonephritis in twelve of the cases.

Seasonal variations in renal biopsy numbers and primary glomerular disease features based on the Japan renal biopsy registry

We analyzed the seasonal variations in the number of renal biopsies and clinical characteristics of primary glomerular disease in Japan using the Japan Renal Biopsy Registry (J-RBR). We retrospectively collected clinical and pathological data of patients with primary glomerular disease who were registered in the J-RBR between 2007 and 2018. Immunoglobulin A nephropathy (IgAN), minimal change nephrotic syndrome (MCNS), membranous nephropathy (MN), and postinfectious acute glomerulonephritis (PIAGN) constituted the four major glomerular disorders included in this study (total, 13,989; IgAN, 9121; MCNS, 2298; MN, 2447; and PIAGN, 123). The number of patients with IgAN or MCNS was higher during summer. However, no overt seasonal variations were observed in patients with MN or PIAGN. Subgroup analyses suggested that in the patients with IgAN, more renal biopsies of severe cases were performed during winter, probably owing to age and blood pressure. Furthermore, more renal biopsies of severe cases were performed during spring and winter in patients with MCNS even after adjusting for the abovementioned host factors. This study suggests that seasonal factors influence the decision to perform renal biopsy as well as the pathogenesis of primary glomerular disease. Thus, our findings may provide important insights regarding the pathophysiology of primary glomerular disease.

Clinical Manifestations, Pathological Correlations, Prognostic Factors, and Outcomes of Severe Acute Postinfectious Glomerulonephritis with Rapidly Progressive Glomerulonephritis in Children

Objective: To describe clinical spectrum, as well as biochemical and histological factors that could predict severe presentations and renal outcomes among children with rapidly progressive glomerulonephritis (RPGN) due to postinfectious glomerulonephritis (PIGN). Material and Methods: A retrospective cohort study was conducted at Chiang Mai University Hospital, Thailand between February 2008 and January 2018. Ninety-six pediatric patients with PIGN were recruited. Clinical presentations, disease courses, laboratory data, renal histopathology, treatment, and outcomes were analyzed. Compare clinical manifestation and outcome between the two groups. Results: The median age (interquartile range, IQR) was 11 (8 to 13) years with a male-to-female ratio of 1.8:1. RPGN was identified in 51.04% (49/96 patients). PIGN children with RPGN exhibited a higher prevalence of nephrotic range proteinuria (69.4% versus 53.2%, p=0.04), nephrotic syndrome (46.9% versus 17%, p=0.002), and hypoalbuminemia (81.3% versus 53.8%, p<0.0001) compared with those without RPGN. Multivariate analysis revealed that anuria, and hypoalbuminemia were predicting factors of RPGN [odd ratios 0.07 (95% CI 0.01 to 0.77), p=0.03 and 0.23 (95% CI 0.08 to 0.69), p=0.006, respectively]. Follow-up data were available among 78 patients (81.3%) with a median follow-up time of 762 (256.3 to 1,293) days. Complete remission was identified in all of PIGN without RPGN but only 71.4% in the RPGN group. Kaplan-Meier analysis revealed that patients with RPGN had a longer recovery time of generalized edema at 14 days (95% CI 12 to 15.9) versus 9 days (95% CI 7 to 12), p=0.023; proteinuria at 16 weeks (95% CI 11 to 20.8) versus 8 weeks (95% CI 4.25 to 15.75), p<0.0001; and impaired glomerular filtration rate (GFR) of nine weeks (95% CI 4.8 to 13.2) versus two weeks (95% CI 1 to 8), p=0.003. Subgroup analysis of prognostic factors of PIGN with RPGN revealed that high BMI z-score and kidney replacement therapy (KRT) requirement were associated with poor renal outcomes. Conclusion: Hypoalbuminemia and anuria were predictive factors of RPGN in PIGN. High BMI z-score and low GFR required acute KRT were predictive factors of poor renal outcomes. Keywords: Postinfectious glomerulonephritis; Acute post streptococcal glomerulonephritis; Rapidly progressive glomerulonephritis; Children

Crescentic glomerulonephritis in children: A retrospective review of data from Chris Hani Baragwanath Academic Hospital

Background. Crescentic glomerulonephritis (CGN) as a cause of progressive renal failure is rare. Crescent formation on kidney biopsyrepresents a response to injury of the glomerular capillary walls. There are limited published reports on paediatric CGN in Africa.Objectives. To describe the clinical presentation and outcome of children with CGN in Soweto, South Africa, over a 22-year period.Methods. A retrospective study was conducted at the Paediatric Renal Unit at Chris Hani Baragwanath Academic Hospital. Childrenyounger than 14 years with crescent formation in more than 50% of glomeruli on renal biopsy were included in the study. Kidney biopsy specimens were examined by light microscopy, immunofluorescence and electron microscopy. Demographic and clinical data were extracted from the patient files.Results. During the study period, 961 kidney biopsies were performed. Fourteen patients (1.5%) met inclusion criteria of crescents in>50% of glomeruli. Common clinical findings were oedema (n=13; 93%), microscopic haematuria (n=12; 86%), hypertension (n=11; 79%)and proteinuria (n=10; 71%). The median estimated glomerular filtration rate (eGFR) at presentation was 23.9 mL/min/1.73m2. Thirteen patients (93%) had immune-complex-mediated glomerulonephritis. The underlying cause was acute post-infectious glomerulonephritis in 9 patients (64%), membranoproliferative glomerulonephritis and IgA nephropathy in 2 patients each (14%) and global sclerosis in 1 patient (7%). Prolonged duration of symptoms resulted in a lower eGFR at follow-up. Treatment included peritoneal dialysis, methylprednisolone and cyclophosphamide. Seven (54%) patients had a normal eGFR at a median (range) follow-up of 36.7 (4.5 - 61.5) months. Six (46%) patients had progressed to chronic kidney disease stages 2 - 5. One patient was followed up for less than 3 months, and therefore was not included in the follow-up results.Conclusion. Poor outcomes were observed in patients who presented late. The clinical findings of haematuria, hypertension and acutekidney injury warrant early referral and kidney biopsy to determine management.

POS-038 EPIDEMIOLOGICAL, CLINICAL AND PROGNOSTIC ASPECTS OF ACUTE POST-INFECTIOUS GLOMERULONEPHRITIS FROM JUNE 2014 TO JUNE 2018: A SINGLE HAITIAN HOSPITAL-BASED STUDY

Acute post-infectious glomerulonephritis (APIGN) is one of the main causes of glomerulonephritis in children with a clear male predominance. It is more common in countries with limited resources and is associated with high morbidity and mortality. Through this study, we wanted to evaluate the burden of this glomerulopathy in children admitted at the only pediatric hospital in Haiti by reviewing its epidemiological, clinical, and prognostic characteristics

Prevalence of Renal Failure in Children and the Need for Dialysis in Paediatric Nephrology in a Developing Country

Background: Renal failure is among the major visceral failures responsible for morbidity and mortality in children. Epidemiological data on renal failure in children are limited in sub-Saharan Africa, including Senegal. We conducted this study to assess the prevalence of renal failure (RF) and the need for dialysis in the paediatric nephrology unit. Patients and methods: This was a retrospective and descriptive study in the pediatric nephrology unit from 1st January 2020 to 30 June 2021, including children with acute or chronic RF. The need for dialysis was judged to be met by its effectiveness in face of an indication. The data collected were analysed on sphinx plus 2017 software. Results: The prevalence of RF was 60% (n/N = 132/220). RF was acute in 59% (n/N = 78/132) of cases. The mean age was 6.53 ± 4.77 years with a sex ratio of 1.8. The mean serum creatinine level was 27.22 mg/L (240.9 μmol/L) and BUN at 0.85 g/L. The aetiologies were dominated by prerenal AKI (Acute Kidney Injury) complicating nephrotic syndrome (NS) in 37.2% (n/N = 29/78) and dehydration due to stomach flu in 17.6% (n/N = 9/51). Acute post-infectious glomerulonephritis including group A streptococcus and plasmodium falciparum accounted for 16.7% (n = 13/78) of intrinsic AKI. The need for dialysis was unmet in 50% (n/N = 7/14) with a mortality of 14.1% (n/N = 11/78). The mean age of the patients with chronic RF was 8.68 ± 4.74 years with a sex ratio of 2.6. The mean serum creatinine level was 36.56 mg/L (323.5 μmol/L) and the BUN level was 0.99 g/L. Half of the children were classified as having CKD stage II (early stage). The aetiologies were dominated by primary focal and segmental glomerulosclerosis (FSGS), 53.7% (n/N = 29/54), renal hypoplasia, 22.2% (n/N = 12/54) and reflux nephropathy, 29.4% (n/N = 5/17). The need for dialysis was unmet in 46.1% (n/N = 6/13). The overall mortality of chronic kidney disease (CKD) with RF was 29.6% (n/N = 8/27). Conclusion: The prevalence of RF was high in the unit. Most aetiologies of AKI were accessible to prevention. Only half of the children had access to free dialysis, hence the need for a dedicated pilot dialysis centre.

Posterior reversible leukoencephalopathy syndrome associated with acute postinfectious glomerulonephritis: systematic review

BackgroundKidney diseases are a recognized cause of posterior reversible leukoencephalopathy syndrome, usually abbreviated as PRES. The purpose of this review was to systematically address the association between acute postinfectious glomerulonephritis and PRES.MethodsWe performed a systematic review of the literature on acute postinfectious glomerulonephritis associated with PRES. The principles recommended by the Economic and Social Research Council guidance on the conduct of narrative synthesis and on the Preferred Reporting Items for Systematic Reviews and Meta-analyses were used. Databases searched included Excerpta Medica, US National Library of Medicine, and Web of Science.ResultsFor the final analysis, we evaluated 47 reports describing 52 cases (32 males and 20 females). Fifty patients were ≤ 18 years of age. Blood pressure was classified as follows: normal-elevated (n = 3), stage 1 hypertension (n = 3), stage 2 hypertension (n = 5), and severe hypertension (n = 41). Acute kidney injury was classified as stage 1 in 32, stage 2 in 16, and stage 3 in four cases. Neuroimaging studies disclosed a classic posterior PRES pattern in 28 cases, a diffuse PRES pattern in 23 cases, and a brainstem-cerebellum PRES pattern in the remaining case. Antihypertensive drugs were prescribed in all cases and antiepileptic drugs in cases presenting with seizures. A resolution of clinical findings and neuroimaging lesions was documented in all cases with information about follow-up.ConclusionsThe main factor associated with PRES in acute postinfectious glomerulonephritis is severe hypertension. Prompt clinical suspicion, rapid evaluation, and management of hypertension are crucial.Graphical abstractA higher resolution version of the Graphical abstract is available as Supplementary information

Гострий гломерулонефрит: особливості перебігу та патоморфологічної картини (власне спостереження)

Наведено клінічний випадок з особливостями морфологічної картини гострого гломерулонефриту, що перебігав на фоні попередньо існуючої патології канальцевого апарату нирок — мікрополікістозу некласифікованого. Хворому Х., 20 років, була проведена патогенетична терапія гострого гломерулонефриту глюкокортикоїдами та цитостатиками. Однак, незважаючи на застосовані терапевтичні засоби, симптоми гломерулонефриту продовжували наростати, розвинувся нефротичний синдром, що призвело до критичної втрати білків плазми крові, розладів коагуляції у вигляді ДВЗ-синдрому та подальшого приєднання уремії. Імовірно, резистентність до лікування пов’язана з попередньо існуючою патологією канальців нирок, функція яких була скомпрометована, та, можливо, генетично детермінованою резистентністю до патогенетичної терапії.

Циліопатії, роль Wnt-сигнального шляху в перебігу гострого (постінфекційного) гломерулонефриту: огляд літератури та власне спостереження

Первинні війки — це субклітинні органели, що є похідними цитоплазматичної мембрани клітин майже будь-якого типу. Вони відіграють роль у сприйнятті та передачі механічних та хімічних сигналів із поверхні клітин, орієнтації площини поділу клітини, органогенезі тощо. Зазначені функції реалізуються завдяки великій кількості білків, рецепторів, сигнальних шляхів. Мутації та дерегуляція даних компонентів можуть мати широкий спектр фенотипових наслідків, що об’єднуються спільною назвою — циліопатії, до яких, зокрема, належать і кістозні ураження паренхіми нирок. Серед інших сигнальних каскадів, пов’язаних з первинними війками, Wnt-сигнальний шлях є відповідальним за нефрогенез та відповідь нирок на ушкоджуючі фактори. Описано клінічний випадок гострого (постінфекційного) гломерулонефриту в пацієнта Х., 20 років, із кістозним розширенням ниркових канальців, що було діагностовано гістологічно. У поданій статті, базуючись на останніх дослідженнях у галузі циліопатій, ми припускаємо ймовірні молекулярні механізми, відповідальні як за формування кіст у канальцевій системі нирок, так і за прогресуючий фатальний перебіг гломерулонефриту в даному випадку.

Eculizumab as a New Treatment for Severe Acute Post-infectious Glomerulonephritis: Two Case Reports

Acute post-infections glomerulonephritis (APIGN) is a frequent cause of glomerulonephritis and represents the most common cause of acute glomerulonephritis in children. It can evolve to severe acute renal failure and chronic kidney disease or even end-stage kidney disease. The precise pathophysiological mechanisms of APIGN are still incompletely understood. The implication of the alternative complement pathway and the potential benefits of C5 blockade have been recently highlighted, in particular in the presence of a C3 Nephritic Factor (C3Nef), anti-Factor B or H autoantibodies. We report two children with severe APIGN, successfully treated with eculizumab. The first patient presented a severe form of APIGN with advanced renal failure and anuria, associated with a decreased level of C3 and an increased level of soluble C5b-9, in the presence of a C3NeF autoantibody. The second case had a severe oliguric APIGN associated with low C3 level. Kidney biopsy confirmed the diagnosis of APIGN in both cases. Eculizumab allowed full renal function recovery and the avoidance of dialysis in both cases. In conclusion, the alternative and terminal complement pathways activation might be common in PIGN, and in severe cases, eculizumab might help.

Global Disease Burden From Acute Glomerulonephritis 1990–2019

Acute glomerulonephritis (GN) is an acute episode of glomerular injury accompanied by inflammation, usually characterizing by edema, hematuria, hypertension, and acute kidney injury.1Vinen C.S. Oliveira D.B.G. Acute glomerulonephritis.Postgrad Med J. 2003; 79 (quiz 212–213): 206-213Crossref PubMed Scopus (23) Google Scholar In the classification of the clinical renal presentation, acute GN (International Classification of Diseases code: N00-N01.9) (Table S1) generally includes nephritic syndrome and rapidly progressive GN.1Vinen C.S. Oliveira D.B.G. Acute glomerulonephritis.Postgrad Med J. 2003; 79 (quiz 212–213): 206-213Crossref PubMed Scopus (23) Google Scholar The clinical outcome of patients with acute GN depends on the disease severity and the underlying cause. Acute post-infectious glomerulonephritis is the most common form of acute GN, particularly in children. Viral, bacterial, and protozoal organisms can cause infections, with subsequent acute post-infectious glomerulonephritis.2Prasad N. Patel M.R. Infection-induced kidney diseases.Front Med. 2018; 5: 327Crossref Scopus (12) Google Scholar With the aging population growing, acute GN is increasingly common in older patients due to the increased rates of endocarditis, which is associated with the ongoing utility of intravenous drugs and cardiac devices.3Boils C.L. Nasr S.H. Walker P.D. et al.Update on endocarditis-associated glomerulonephritis.Kidney Int. 2015; 87: 1241-1249Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar Thus, not only younger children but also older adults are affected by this disease. In addition to acute post-infectious glomerulonephritis, the other forms of acute GN include immunoglobulin A nephropathy and rapidly progressive GN.1Vinen C.S. Oliveira D.B.G. Acute glomerulonephritis.Postgrad Med J. 2003; 79 (quiz 212–213): 206-213Crossref PubMed Scopus (23) Google Scholar Immunoglobulin A nephropathy is characterized by a mesangial proliferative GN. Rapidly progressive GN has the potential to destroy renal function within days. These forms of acute GN usually cannot be expected to resolve spontaneously.1Vinen C.S. Oliveira D.B.G. Acute glomerulonephritis.Postgrad Med J. 2003; 79 (quiz 212–213): 206-213Crossref PubMed Scopus (23) Google Scholar Acute GN can result in acute renal failure requiring dialysis and intensive care and results in economic costs to families and the health system. Therefore, we do not turn a blind eye to the disease burden of acute GN. Previous predominantly single-center studies have described the clinical characteristics, complications, and clinical outcome of adults and children with acute GN.4Eison T.M. Ault B.H. Jones D.P. et al.Post-streptococcal acute glomerulonephritis in children: clinical features and pathogenesis.Pediatr Nephrol. 2011; 26: 165-180Crossref PubMed Scopus (88) Google Scholar,5Dowler J. Wilson A. Acute post-streptococcal glomerulonephritis in Central Australia.Australian J Rural Health. 2020; 28: 74-80Crossref PubMed Scopus (2) Google Scholar However, a large-scale systematic analysis of the global disease burden of acute GN is lacking. The Global Burden of Disease (GBD) Study 2019 provides up-to-date data regarding the epidemiology of acute GN for 195 countries and territories from 1990 to 2019.6Diseases G.B.D. Injuries C. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet. 2020; 396: 1204-1222Abstract Full Text Full Text PDF PubMed Scopus (541) Google Scholar Using this data source, we analyzed rates in 2019, and temporal trends between 1990 and 2019, for the point prevalence, incidence, disability-adjusted life-years (DALYs), and mortality (Table S2) associated with acute GN at a global, regional, and national level. Globally, there were 48,375 point prevalent cases, 722,244 incident cases, 10,522 deaths, and 307,480 DALYs attributed to acute GN in 2019. The age-standardized rates in 2019 for prevalence per 100,000 population were 0.63 (95% uncertainty interval [UI], 0.52 to 0.76), for incidence was 9.45 (95% UI, 7.72 to 11.55), the mortality rate was 0.13 (95% UI, 0.10 to 0.16), and the DALY rate was 3.90 (95% UI, 2.57 to 4.61) (Table 1). The highest age-standardized rates were in North Korea (1.75; 95% UI, 1.27 to 2.32) for prevalence, in Vietnam (25.44; 95% UI, 19.32 to 32.90) for incidence, in China (0.40; 95% UI, 0.27 to 0.46) for mortality, and in Timor-Leste (21.70; 95% UI, 8.04 to 32.32) for DALYs (rate per 100,000 population in 2019) (Table 1, Figure 1). These rates decreased significantly from 1990 to 2019 per year. Generally, East Asia had the highest decreased trend of age-standardized prevalence and age-standardized incidence rate during 1990 to 2019, respectively. Eastern Europe had the highest decreased trend of age-standardized mortality and age-standardized DALYs over the same period. By contrast, the highest increased trend in age-standardized incidence and age-standardized prevalence rate was in South Asia. At the same time, North Africa and Middle East, High-income North America, and Central Latin America had the highest increased trends of age-standardized mortality and age-standardized DALYs from 1990 to 2019 (Table 1, Figure S1). The national age-standardized rates and trends of prevalence, incidence, mortality, and DALYs across the 195 countries and territories were seen in Table S3. Here, we found the highest disease burden in Asian countries, particularly in Brunei, Uzbekistan, Vietnam, and North Korea with the highest prevalence and incidence, and in China, Laos, Afghanistan, North Korea, and Cambodia with the highest mortality and DALYs.Table 1Numbers, age-standardized rates of prevalence, incidence, mortality, and disability-adjusted life years from acute glomerulonephritis in 2019, and trends from 1990 to 2019 in the global and regional levelsVariablesPrevalenceCount (IQR)Age-standardized prevalence (95% UI)Annual percent change in rate (CI)aPercent change in rate refer to average annual percent changes between 1990 and 2019.Prevalence Global level48,375 (39,386, 58,295)0.63 (0.52 to 0.76)-1.92 (-2.14, -1.69) Male25,791 (21,044, 31,044)0.67 (0.55 to 0.8)-2.02 (-2.26, -1.78) Female22,583 (18,339, 27,267)0.60 (0.48 to 0.72)-1.81 (-2.02, -1.6) Regional levelLow SDI6196 (4870, 7745)0.55 (0.45 to 0.67)0.54 (0.43, 0.66)Low-middle SDI13,997 (11,377, 16,925)0.78 (0.64 to 0.93)-0.1 (-0.18, -0.02)Middle SDI15,894 (12903,19163)0.69 (0.56 to 0.83)-2.75 (-3.12, -2.37)High-middle SDI8427 (6902, 10,229)0.62 (0.5 to 0.75)-3.28 (-3.66, -2.9)High SDI3832 (3121, 4605)0.41 (0.32 to 0.5)-0.74 (-0.8, -0.68) Andean Latin America202 (154, 259)0.32 (0.24 to 0.41)0.24 (0.11, 0.37) Australasia93 (69, 120)0.35 (0.25 to 0.47)-0.02 (-0.07, 0.04) Caribbean279 (207, 363)0.6 (0.44 to 0.78)0.18 (0.15, 0.2) Central Asia1377 (1078, 1753)1.45 (1.14 to 1.84)-0.46 (-0.64, -0.28) Central Europe936 (753, 1150)0.94 (0.74 to 1.18)-0.18 (-0.28, -0.08) Central Latin America1166(904,1468)0.48 (0.37 to 0.6)-0.24 (-0.4, -0.07) Central sub-Saharan Africa590 (425, 776)0.49 (0.37 to 0.63)-0.04 (-0.1, 0.02) East Asia6805 (5516, 8513)0.53 (0.42 to 0.66)-5.34 (-6.1, -4.58) Eastern Europe2876 (2412, 3448)1.3 (1.09 to 1.55)-1.62 (-1.86, -1.38) Eastern sub-Saharan Africa2144 (1641, 2738)0.54 (0.43 to 0.67)-0.11 (-0.16, -0.05) High-income Asia Pacific1939 (1558, 2345)1.41 (1.08 to 1.80)0.27 (0.21, 0.33) High-income North America526 (457, 600)0.12 (0.10 to 0.14)-0.32 (-0.49, -0.14) North Africa and Middle East2683 (2092, 3415)0.46 (0.36 to 0.58)0.96 (0.91, 1.01) Oceania128 (91, 174)0.91 (0.67 to 1.19)0.21 (0.17, 0.25) South Asia14,564 (11,840, 17,670)0.78 (0.64 to 0.94)1.75 (1.44, 2.07) Southeast Asia6790 (5344, 8557)1.05 (0.83 to 1.34)-0.85 (-0.95, -0.74) Southern Latin America131 (97, 174)0.19 (0.14 to 0.26)0.01 (-0.13, 0.16) Southern sub-Saharan Africa398 (321, 489)0.5 (0.41 to 0.61)0.09 (0.04, 0.14) Tropical Latin America2889 (2385, 3516)1.43 (1.17 to 1.78)-1.14 (-1.32, -0.97) Western Europe682 (535, 853)0.17 (0.13 to 0.22)0.01 (-0.07, 0.1) Western sub-Saharan Africa1176 (886, 1497)0.26 (0.2 to 0.32)0.26 (0.19, 0.32)Incidence Global level722,244 (595,182, 877,834)9.45 (7.72 to 11.55)-1.84 (-2.05, -1.62) Male384,881 (317,618, 466,573)10 (8.23 to 12.16)-1.94 (-2.17,-1.71) Female337,363 (277,087, 410,579)8.91 (7.23 to 10.9)-1.72 (-1.93 ,-1.52) Regional levelLow SDI90,785 (71,609, 113,621)8.13 (6.57 to 9.93)0.53 (0.39, 0.68)Low-middle SDI209,162 (171,704, 254,192)11.71 (9.67 to 14.18)-0.04 (-0.12, 0.05)Middle SDI229,525 (188,587, 279,710)9.96 (8.15 to 12.2)-2.49 (-2.81, -2.17)High-middle SDI124,479 (102,778, 150,652)9.13 (7.41 to 11.24)-3.23 (-3.61, -2.86)High SDI56,795 (47,068, 68,265)6.00 (4.78 to 7.51)-0.75 (-0.81, -0.68) Andean Latin America3034 (2312, 3921)4.79 (3.65 to 6.18)0.25 (0.12, 0.38) Australasia1368 (1037, 1770)5.15 (3.79 to 6.85)-0.03 (-0.09, 0.03) Caribbean4196 (3119, 5510)9.01 (6.67 to 11.88)0.16 (0.14, 0.19) Central Asia20,600 (16,148, 26,447)21.67 (16.95 to 27.73)-0.39 (-0.55, -0.23) Central Europe13,940 (11,329, 17,197)13.98 (11.1 to 17.69)-0.18 (-0.27, -0.08) Central Latin America17,472 (13,693, 22,068)7.17 (5.63 to 9.05)-0.27 (-0.43, -0.11) Central sub-Saharan Africa8854 (6432, 11,696)7.46 (5.69 to 9.59)0 (-0.06, 0.05) East Asia97,614 (79,539, 119,180)7.65 (6.16 to 9.4)-5.34 (-6.1, -4.57) Eastern Europe43,027 (36,442, 51,278)19.53 (16.55 to 23.27)-1.5 (-1.73, -1.27) Eastern sub-Saharan Africa32,783 (25,239, 41,795)8.31 (6.66 to 10.38)-0.12 (-0.17, -0.06) High-income Asia Pacific28,660 (23,389, 34,876)20.76 (16.04 to 26.93)0.26 (0.2, 0.32) High-income North America7723 (6781, 8749)1.76 (1.56 to 2)-0.36 (-0.53, -0.2) North Africa and Middle East39,991 (31,202, 51,879)6.88 (5.4 to 8.72)0.92 (0.87, 0.96) Oceania1938 (1400, 2654)13.73 (10.09 to 18.28)0.2 (0.16, 0.24) South Asia220,143 (180,802, 265,753)11.86 (9.88 to 14.25)1.72 (1.4, 2.04) Southeast Asia101,025 (79,100, 129,176)15.73 (12.31 to 20.21)-0.82 (-0.92, -0.72) Southern Latin America1969 (1479, 2559)2.87 (2.15 to 3.79)0 (-0.15, 0.15) Southern sub-Saharan Africa6005 (4851, 7402)7.56 (6.2 to 9.27)0.1 (0.05, 0.15) Tropical Latin America43,849 (36,483, 52,981)21.8 (17.88 to 26.71)-1.11 (-1.28, -0.93) Western Europe10,091 (8034, 12,503)2.55 (1.99 to 3.28)0 (-0.09, 0.08) Western sub-Saharan Africa17,961 (13,753, 22,763)3.93 (3.11 to 4.9)0.23 (0.17, 0.29)Mortality Global level10,522 (7199, 12,200)0.13 (0.09 to 0.15)-2.89 (-3.15, -2.63) Male5670 (2969, 6847)0.16 (0.08 to 0.19)-2.67 (-2.96, -2.38) Female4853 (3784, 5980)0.11 (0.09 to 0.14)-3.17 (-3.4, -2.94) Regional levelLow SDI548 (153, 1053)0.08 (0.02 to 0.18)-2.1 (-2.19, -2.02)Low-middle SDI1971 (1010, 2297)0.15 (0.08 to 0.18)-2.86 (-3.01, -2.7)Middle SDI5502 (3660, 6453)0.24 (0.17 to 0.29)-2.86 (-3.18, -2.55)High-middle SDI1945 (1539, 2256)0.1 (0.08 to 0.12)-4.07 (-4.37, -3.77)High SDI554 (476, 606)0.03 (0.02 to 0.03)-0.02 (-1.15, 1.1) Andean Latin America8 (6, 11)0.02 (0.01 to 0.02)-5.41 (-6.06, -4.75) Australasia7 (6, 9)0.01 (0.01 to 0.02)-0.65 (-3.21, 1.91) Caribbean17 (10, 27)0.04 (0.02 to 0.06)-1.42 (-1.99, -0.85) Central Asia110 (93, 134)0.12 (0.1 to 0.15)-3.79 (-4.55, -3.03) Central Europe41 (35, 47)0.02 (0.02 to 0.02)-5.18 (-6.2, -4.16) Central Latin America281 (242, 320)0.12 (0.11 to 0.14)3.2 (0.57, 5.84) Central sub-Saharan Africa110 (30, 221)0.18 (0.04,0.41)-1.33 (-1.62, -1.05) East Asia7175 (4789, 8407)0.39 (0.27 to 0.45)-3.24 (-3.5, -2.97) Eastern Europe156 (132, 182)0.05 (0.05 to 0.06)-7.86 (-8.72, -7) Eastern sub-Saharan Africa317 (76, 761)0.15 (0.03 to 0.41)-2.74 (-2.83, -2.65) High-income Asia Pacific151 (119, 172)0.03 (0.02 to 0.03)-1.52 (-1.75, -1.29) High-income North America269(236,297)0.04 (0.04 to 0.04)2.99 (0.25, 5.73) North Africa and Middle East424 (58, 528)0.1 (0.02 to 0.12)3.17 (2.66, 3.69) Oceania4 (1, 8)0.04 (0.01 to 0.08)0.04 (-0.18, 0.25) South Asia171 (124, 226)0.01 (0.01 to 0.02)-3.9 (-4.06, -3.74) Southeast Asia1060 (311, 1464)0.19 (0.06 to 0.26)-3.17 (-3.28, -3.05) Southern Latin America3 (2, 3)0.003 (0.0029 to 0.004)-3.56 (-4.75, -2.38) Southern sub-Saharan Africa35 (30, 41)0.06 (0.05 to 0.06)-0.69 (-0.98, -0.39) Tropical Latin America58 (53, 63)0.03 (0.02 to 0.03)-6.15 (-6.71, -5.59) Western Europe92 (80, 101)0.0087 (0.008 to 0.009)-1.18 (-3, 0.65) Western sub-Saharan Africa34 (12, 63)0.01 (0 to 0.02)-1.94 (-2.13, -1.75)DALYs Global level307,480 (204,185, 362,573)3.90 (2.57 to 4.61)-3.89 (-4.08, -3.7) Male168,933 (84,118, 207,613)4.39 (2.18 to 5.36)-3.59 (-3.81, -3.36) Female138,547 (94,777, 178,442)3.46 (2.29 to 4.5)-4.24 (-4.38, -4.09) Regional levelLow SDI27,352 (8248, 47,095)2.67 (0.77 to 5.1)-2.7 (-2.77, -2.63)Low-middle SDI62,601 (31,604, 74,473)4.05 (2.05 to 4.79)-3.96 (-4.09, -3.83)Middle SDI158,186 (102,853, 185,699)6.61 (4.28 to 7.72)-3.77 (-4.05, -3.49)High-middle SDI50,545 (41,348, 58,939)2.86 (2.32 to 3.33)-5.02 (-5.29, -4.75)High SDI8668 (7820, 9364)0.52 (0.48 to 0.56)-0.78 (-1.77, 0.21) Andean Latin America241 (162, 333)0.4 (0.28 to 0.56)-7.11 (-7.79, -6.44) Australasia123 (101, 148)0.28 (0.23 to 0.33)-1.06 (-3.2, 1.09) Caribbean782 (423, 1369)1.73 (0.92 to 3.08)-1.58 (-2.04, -1.11) Central Asia4728 (3952, 5765)4.99 (4.20 to 6.04)-3.82 (-4.57, -3.07) Central Europe1012 (871, 1163)0.65 (0.56 to 0.75)-5.72 (-6.68, -4.76) Central Latin America6802 (5875, 7754)2.84 (2.45 to 3.23)2.1 (-0.38, 4.58) Central sub-Saharan Africa5067 (1465, 10,186)4.98 (1.38 to 10.05)-2.17 (-2.48, -1.86) East Asia183,639 (125,297, 217,608)10.17 (7.02 to 11.93)-4.18 (-4.41, -3.95) Eastern Europe5495 (4680, 6414)2.14 (1.83 to 2.5)-7.96 (-8.81, -7.11) Eastern sub-Saharan Africa15,382 (4016, 31,248)4.49 (1.09 to 10.97)-3.55 (-3.65, -3.45) High-income Asia Pacific2029 (1723, 2241)0.51 (0.45 to 0.56)-1.48 (-1.71, -1.26) High-income North America4107 (3772, 4440)0.71 (0.66 to 0.76)2.65 (0.02, 5.27) North Africa and Middle East16,079 (2321, 20,747)2.97 (0.44 to 3.79)2.74 (2.25, 3.24) Oceania190 (44, 428)1.51 (0.36 to 3.22)0.17 (-0.08, 0.43) South Asia6692 (4863, 8314)0.41 (0.3 to 0.51)-3.94 (-4.04, -3.84) Southeast Asia47,484 (11,297, 64,070)7.66 (1.88 to 10.42)-3.7 (-3.85, -3.56) Southern Latin America73 (62, 87)0.10 (0.09 to 0.13)-3.65 (-4.52, -2.78) Southern sub-Saharan Africa1510 (1279, 1824)2.01 (1.72 to 2.41)-1.63 (-1.95, -1.31) Tropical Latin America2410 (2181, 2656)1.19 (1.06 to 1.33)-6.9 (-7.35, -6.44) Western Europe1311 (1182, 1418)0.17 (0.15 to 0.18)-1.67 (-3.2, -0.15) Western sub-Saharan Africa2323 (695, 4595)0.41 (0.15 to 0.76)-2.06 (-2.27, -1.84)CI, confidence interval; DALY, disability-adjusted life-years; IQR, interquartile range; SDI, sociodemographic index; UI, uncertainty interval.a Percent change in rate refer to average annual percent changes between 1990 and 2019. Open table in a new tab CI, confidence interval; DALY, disability-adjusted life-years; IQR, interquartile range; SDI, sociodemographic index; UI, uncertainty interval. Notably, acute GN most often results from a soft tissue infection such as beta-hemolytic streptococci pharyngitis in children, namely acute post-streptococcal GN.7Balasubramanian R. Marks S.D. Post-infectious glomerulonephritis.Paediatr Int Child Health. 2017; 37: 240-247Crossref PubMed Scopus (15) Google Scholar Consistent with the previous studies, we found that the highest rate of prevalence and incidence occurred in children. As shown in Figure S2, the initial increased peak in the age-standardized prevalence and incidence was, respectively, in the 10 to 14 age group, followed by a decline in younger adults, and accompanied by a small wave with some fluctuations in the older population. Acute GN can also occur in adults. Most previous studies about acute GN were limited to children with acute post-streptococcal GN. Therefore, studies involving adults are needed. Different forms of acute GN occur in elderly people, especially those who are immunocompromised with health conditions such as diabetes. For example, protozoal and viral infections in the skin occur more frequently than streptococcal pharyngeal infections as a cause of acute GN in elderly patients.8Hamouda M. Mrabet I. Dhia N.B. et al.Acute post-infectious glomerulonephritis in adults: a single center report.Saudi J Didney Dis Transpl. 2014; 25: 567-571Crossref PubMed Scopus (5) Google Scholar Also, immunoglobulin A nephropathy and membranoproliferative GN can result in acute GN8Hamouda M. Mrabet I. Dhia N.B. et al.Acute post-infectious glomerulonephritis in adults: a single center report.Saudi J Didney Dis Transpl. 2014; 25: 567-571Crossref PubMed Scopus (5) Google Scholar; membranous GN is the underlying cause of acute GN in the elderly due to a variety of malignancies including carcinoma of the lung, stomach, breast, and colon. Rapidly progressive GN can result in acute kidney injury requiring dialysis, and become a major contributor to morbidity and disability within the growing aging population. In this study, we found that the age-standardized rates of mortality and DALYs increased with age, and peaked in the 80- to 85-year-old age groups in 2019 (Figure S2). These rates were slightly higher in males than in females, although no statistically significant differences were observed. Distributions of these rates were similar to those of case numbers of prevalence, incidence, mortality, and DALYs in 2019 (Figure S3). Thus, policymakers should take the elderly population into account when deciding on approaches to reducing the disease burden of acute GN in the future. In this study, no association was found between age-standardized incidence, age-standardized prevalence rates or sociodemographic index (SDI) in 2019 regionally and nationally (Figure S4 and S5). However, a negative association between SDI and age-standardized mortality as well as DALYs was observed. Similar results were also seen in expected age-standardized rates based on their own SDI values in 21 regions (Figure S6–S9). Notably, East Asia and Southeast Asia had a higher observed burden than expected to mortality and disability from 1990 to 2019 (Figure S8 and S9). Likewise, countries and territories such as China, Myanmar, Timor-Leste, Cambodia, Laos, and North Korea had much higher observed age-standardized mortality and DALYs than expected in 2019 (Figure S10 and S11). These results indicated that the burden of acute GN may be generally higher at lower socioeconomic levels of development possible due to the higher frequency of acute post-infectious glomerulonephritis. The underlying reason may be explained by the hygiene hypothesis, namely, early and frequent exposure to bacterial antigens is more common in developing countries than in industrialized nations, which had fewer infections due to better public hygiene.9Hurtado A. Johnson R.J. Hygiene hypothesis and prevalence of glomerulonephritis.Kidney Int Suppl. 2005; : S62-S67Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Thus, increasing population awareness about these relations is warranted to reduce the future burden of acute GN, particularly in the Asia region. In conclusion, the prevalence, incidence, mortality, and disability related to acute GN have decreased globally. But a high disease burden remains in children and elderly people, particularly in some Asian regions. Increasing awareness about acute GN in these populations is warranted to reduce the future burden of acute GN. This work is supported by Zhejiang Provincial Natural Science Foundation of China (LY19H080009). The funders had no role in study design, data collection, data analysis, interpretation, writing of this report. The authors thank the GBD collaborator and the IHME leaders who provided the methodologies and datasets in GBD studies; and Yansmin Elhajmoussa at City of Hope/Biomedical Research Center (BRC) at Gehr Leukemia Center for polishing the language of the article. QG and SW contributed equally. The GBD study 2019, conducted by Institute of Health Metrics and Evaluation (IHME), provides the available datasets. IHME uses de-identified and aggregated data, so informed consent is not applicable to the GBD study. This manuscript is a review article and does not involve a research protocol requiring approval by the relevant institutional review board or ethics committee. Download .pdf (2.29 MB) Help with pdf files Supplementary File (PDF) Table S1. International Classification of Diseases code (N00-N01.9) as reference to diagnosis acute GN in this study. Table S2. Definitions of measure metrics in GDB 2019. Table S3.Numbers, age-standardized rates of prevalence, incidence, mortality and disability-adjusted life years from acute glomerulonephritis in 2019, and trends from 1990 to 2019 in GBD study in the national levels. Figure S1. Annual percentage changes of prevalence, incidence, mortality, and disability-adjusted life years for 21 regions in 2019. APCpre, APCinc, APCmort, and APCdaly represent annual percent changes of prevalence, incidence, mortality, and disability-adjusted life years, respectively. Figure S2. Age-standardized point prevalence (A), incidence (B), mortality (C) and disability-adjusted life years (D) for acute glomerulonephritis per 100,000 population by sex and age in 2019. Red and green lines represent females and males, respectively. Figure S3. Global number of prevalent cases (A), incident cases (B), mortality cases (C), and DALYs cases (D) by sex and age in 2019. Figure S4. Correlation relationship among sociodemographic index (SDI) and age-standardized rates of prevalence (ASPR), incidence (ASIR), mortality (ASMR), and disability-adjusted life years (DALYs) in 21 regions in 2019. Figure S5. Correlation relationship among sociodemographic index (SDI) and age-standardized rates of prevalence (Pre), incidence (Inc), mortality (Mort), and disability-adjusted life years (DALYs) in 195 countries in 2019. Figure S6. The estimated relation between SDI and expected age-standardized prevalence from 1900 to 2019 in 21 regions. Figure S7. The estimated relation between SDI and expected age-standardized incidence (ASIR) from 1900 to 2019 in 21 regions. Figure S8. The estimated relation between SDI and expected age-standardized mortality (ASMR) from 1900 to 2019 in 21 regions. Figure S9. The estimated relation between SDI and expected age-standardized disability-adjusted life years (DALYs) from 1900 to 2019 in 21 regions. Figure S10. Age-standardized DALYs rate for acute glomerulonephritis per 100,000 population for 195 countries by sociodemographic index in 2019. Figure S11. Age-standardized mortality rate for acute glomerulonephritis per 100,000 population for 195 countries by sociodemographic index in 2019. Gray ribbon represents expected disease rates based on sociodemographic index in all countries. Points are plotted for the observed age-standardized mortality rate in each country.

Acute Kidney Injury in a Patient with Trisomy 21.

A 5-year-old former 34-week girl with trisomy 21, hypothyroidism, and obstructive sleep apnea presents to the emergency department with a chief complaint of fever. She initially presented to her pediatrician 3 weeks earlier with sore throat and was diagnosed as having group A streptococcal pharyngitis. She completed 10 days of amoxicillin with resolution of sore throat. Now for the past 3 days she has had fever, chest pain, decreased enteral intake, and emesis. Review of systems is negative for diarrhea, gross hematuria, dysuria, polyuria, polydipsia, edema, weight loss, rash, arthralgia, arthritis, oral ulcers, epistaxis, and hemoptysis. She has had normal growth. She takes levothyroxine and took several doses of ibuprofen for fever over the past several weeks. There is no family history of kidney disease. She had no recent travel or sick contacts.On physical examination her weight is 45.2 lb (20.5 kg) (65th percentile); height, 46.1 in (117 cm) (62% percentile); temperature, 100.8°F (38.2°C); heart rate, 110 beats/min; respiratory rate, 24 breaths/min; oxygen saturation, 100% on room air; and blood pressure, 92/42 mm Hg (systolic 31st and diastolic 9th percentiles for age and sex). There is no pharyngeal injection or exudate. She appears well-hydrated, including moist mucous membranes. Lungs are clear to auscultation. Her abdomen is soft, nontender, and nondistended. There is no edema, and she has brisk capillary refill. She has no rash or joint swelling, erythema, or warmth. Laboratory evaluation includes a white blood cell count of 15,310/µL (15.31×109/L) with 83.6% neutrophils and 0.8% bands; hemoglobin level, 8.1 g/dL (81 g/L); platelet count, 474×103/µL (474×109/L); and elevated C-reactive protein level, 21.3 mg/dL (213 mg/L; reference range, <0.5 mg/dL [<5 mg/L]) to assess for signs of infection/inflammation. A metabolic panel is obtained given the patient’s history of decreased intake and emesis and shows the following levels: sodium, 132 mEq/L (132 mmol/L); potassium, 7.5 mEq/L (7.5 mmol/L); carbon dioxide, 20 mEq/L (20 mmol/L); blood urea nitrogen (BUN), 69 mg/dL (24.6 mmol/L); creatinine, 6.5 mg/dL (495.6 µmol/L); and albumin, 3.4 g/dL (34 g/L). Urinalysis has specific gravity 1.012, 2+ protein, negative glucose, small hemoglobin, negative nitrites, large leukocyte esterase, 170 white blood cells per high-power field, 6 red blood cells per high-power field, and a urine protein to creatinine ratio of 0.94 mg protein/mg creatinine. There are no urinary casts. Fractional excretion of sodium is calculated to be 2.1%. Blood and urine cultures are obtained. Given the elevated creatinine level and abnormal urine test results, ultrasonography is performed, which shows large hyperechoic kidneys for age without hydronephrosis (right kidney, 9.9 cm; left kidney, 10.4 cm) and a normal bladder. There are no renal calculi or masses. There is normal renal arterial and venous Doppler flow. A chest radiograph obtained to evaluate for pneumonia given chest pain in the setting of fever shows a left upper lobe opacity. She has a normal echocardiogram. Of note, she had normal levels of electrolytes, BUN, and creatinine (0.36 mg/dL [31.82 µmol/L]) 5 months earlier during an emergency department visit for a respiratory tract infection.This 5-year-old girl with trisomy 21 presented with a markedly elevated serum creatinine level after 3 days of fever, chest pain, and emesis a few weeks after having had successfully treated streptococcal pharyngitis. She had normal blood pressure. Additional laboratory findings included severe hyperkalemia, elevated white blood cell count and C-reactive protein level, and moderate proteinuria without significant hematuria. The normal serum creatinine level of 0.36 mg/dL (31.82 µmol/L) several months earlier, structurally normal kidneys on ultrasonography, and normal growth are most suggestive of acute kidney injury (AKI) as opposed to previously undiagnosed chronic kidney disease (CKD). Potential causes of AKI in this patient include prerenal AKI, acute tubular necrosis, acute interstitial nephritis, acute glomerulonephritis (GN), and shunt nephritis.Prerenal AKI is possible given her reported history of decreased enteral intake and emesis. However, she did not appear dehydrated on physical examination. An elevated fractional excretion of sodium value also argues against a prerenal etiology, although this test must be interpreted with caution in the setting of tubular injury. The BUN to creatinine ratio was 10. However, this ratio may not be reliable in differentiating dehydration from intrinsic renal injury with this degree of AKI. Acute tubular necrosis as a result of prolonged renal hypoperfusion, enhanced by exposure to nonsteroidal anti-inflammatory drugs, is another possible cause of AKI in this patient. Acute interstitial nephritis as a result of nephrotoxin exposures, including amoxicillin and ibuprofen, should also be considered.The history of antecedent streptococcal pharyngitis raises the possibility of acute postinfectious GN. However, acute postinfectious GN was thought to be less likely in this patient given minimal hematuria and no hypertension, although some patients with acute postinfectious GN can have more mild phenotypes. Other etiologies of acute GN to consider include immunoglobulin (Ig) A nephropathy, pulmonary-renal syndromes such as antineutrophil cytoplasmic antibody (ANCA) vasculitis and Goodpasture syndrome given the focal consolidation seen on chest radiography, and systemic lupus erythematosus (SLE). However, she had no other clinical features suggestive of vasculitis or SLE. To further evaluate for potential causes of GN, additional laboratory studies were sent, including complement levels, antinuclear antibody, and ANCA. Complement 3 and 4 levels were in the normal range, making acute postinfectious or SLE nephritis less likely. Antinuclear antibody and ANCA were negative.Finally, given the increased incidence of congenital heart disease in children with trisomy 21, endocarditis with secondary immune complex (shunt) nephritis should be considered. However, she had a normal echocardiogram and no other physical signs to support endocarditis, so this diagnosis was thought to be less likely.Hyperkalemia was acutely managed with intravenous calcium gluconate, sodium bicarbonate, insulin/glucose, and oral sodium polystyrene sulfonate. Albuterol was not used in this patient, but this is another option for managing hyperkalemia because β-agonists temporarily shift extracellular potassium to the intracellular space. Despite medical therapy for 12 hours, she had persistent hyperkalemia, so a temporary central venous catheter was placed for initiation of hemodialysis. Her creatinine level peaked at 8.6 mg/dL (760.24 µmol/L).A kidney biopsy was performed given severe AKI of unclear etiology. Light microscopy included 18 glomeruli per section. All glomeruli were normal, with no evidence of proliferation, inflammation, or thrombosis. There was extensive tubulointerstitial inflammation, which consisted primarily of neutrophils with occasional lymphocytes (Fig 1). The tubular lumens were full of neutrophils with disruption of normal tubular architecture (Fig 2). Immunofluorescence showed nonspecific mesangial staining close to the glomerular vascular pole for IgG 2-3+, IgA 2-3+, C1q 2-3+, kappa 2-3+, lambda 2-3+, with trace staining for C3 and negative staining for IgM. Electron microscopy showed normal glomeruli with normal thickness and texture of glomerular basement membranes and no podocyte foot process effacement. Weigert stain showed gram-positive organisms within the intratubular casts (Fig 3). These findings were suggestive of extensive acute pyelonephritis.On hospital day 2, her blood culture grew group A Streptococcus pyogenes. Given the left upper lobe opacity seen on chest radiography, the bacteremia was thought to be possibly secondary to pneumonia. Her urine culture returned negative. Despite negative urine culture, her biopsy showed histologic evidence of pyelonephritis with Gram-stain positivity for gram-positive organisms. In the setting of a positive blood culture and histologic evidence of pyelonephritis, she was diagnosed as having acute pyelonephritis due to hematogenous seeding by group A S pyogenes. She was treated with intravenous ceftriaxone. She required hemodialysis for 2 days and then had improvement in urine output and stabilization in hyperkalemia. Her creatinine level steadily improved over the next 9 days to 1.1 mg/dL (97.24 µmol/L) at the time of hospital discharge. She completed a total of 3 weeks of antibiotics, including intravenous ceftriaxone followed by oral amoxicillin. Four weeks after hospital discharge her creatinine level had returned to her previous baseline of 0.5 mg/dL (44.20 µmol/L).Given her severe AKI requiring dialysis, the patient should be followed longitudinally to monitor for CKD. With severe AKI, it is possible to have nephron loss due to scarring, even if the serum creatinine level returns to normal. (1) The risk of CKD is particularly high in patients who have recurrent episodes of AKI. (2) In a retrospective study of 359 patients hospitalized from 2000 to 2010 with a previous episode of AKI, 250 AKI episodes were observed among 122 patients. Of those with recurrent AKI, the hazard of CKD was 2.2 times greater in those who had recurrent AKI than in those who did not have recurrent AKI (P < .005). (3)Pyelonephritis is an infection of the upper urinary tract. (4) When pyelonephritis occurs secondary to infection from the lower urinary tract, the urine culture is typically positive. The patient in this case had a negative urine culture, which may have occurred for several reasons. One possibility is that she had pyelonephritis due to hematogenous seeding from bacteremia as evidenced by the Weigert stain on biopsy showing gram-positive organisms. A study of kidney transplant patients with acute graft dysfunction in whom urine cultures and biopsies had been performed reported a prevalence of 19% (5 of 26 persons) with biopsy findings consistent with pyelonephritis and a negative urine culture. These patients also reported no lower urinary tract symptoms. (5) Urine culture results can also be negative in the setting of pyelonephritis if the urine sample was collected after antibiotic administration. The patient did receive a 10-day course of amoxicillin within a month of presentation with AKI. Finally, urine culture results can be negative in the setting of renal parenchymal infection if the infection is localized, such as in the case of renal abscesses and struvite stones, which can harbor bacteria in a matrix of minerals and biofilm. (6)(7)The prevalence of pyelonephritis varies based on age group. Urinary tract infections are estimated to occur in 1% to 3% of school-age children. (8) AKI may occur in the context of pyelonephritis related to acute tubulointerstitial inflammation, dehydration, and concurrent nephrotoxin exposure. However, the incidence of severe AKI requiring dialysis in the setting of pyelonephritis is rare. In a study of adults, 12.3% of patients admitted to the hospital with urinary tract infections were noted to have AKI. Of those patients, only 0.5% required dialysis. (9)

POS-157 ACUTE POST-INFECTIOUS GLOMERULONEPHRITIS IN CHILDREN: ABOUT A SERIES OF 83 CASES

Post-infectious acute glomerulonephritis (PI-AGN) is very common among Moroccan children. IT can be defined as an acute, non-suppurative, diffuse, generalized inflammation of the glomeruli of both kidneys. It occurs after an infection (of the skin or the upper respiratory tract). Group A beta-hemolytic (GABH) streptococcus is the most incriminated infectious agent. PI-AGN prognosis depends on the severity of renal involvement, with the possibility of chronic renal disease in the worst cases. The aim of our study is to determine the epidemiological, clinical, histological, and evolutive features of PI-AGN in children treated in our center. For that reason, we gathered retrospective data of 83 children. The study took place from January 2016 to June 2020. The median of age was 9 years. Distribution by sex was in favor of males with 65%. Most cases (91%) were seen in winter. The most involved infectious sites were the upper respiratory tract (74%), and the skin (24%). The infection was still active at diagnosis in 30% of cases, while the remaining cases had it at least one week before. Microscopic hematuria and proteinuria were always present. Gross hematuria, generalized edema, and hypertension were also very common (seen respectively in 77%, 82%, and 65% of the cases). Other symptoms reported at diagnosis of PI-AGN were abdominal pain and vomiting (71%), convulsions (17%), and oliguria (13.3%). Acute kidney failure was found at onset in 25 children, from whom two had dialysis. The C3 complement fraction was low in 68 patients, and the ASLO titers were high in 53% of cases. All patients were under water and salt restriction. Furosemide was the first-line treatment of hypertension and oliguria patients, and nicardipine was added when blood pressure targets were not achieved. Renal biopsy was performed on 14 children. The main indications were nephrotic syndrome, persistent proteinuria, rapidly progressive glomerulonephritis (respectively in 22, eight, four, and two patients). The renal biopsy findings were as follows: endocapillary GN with C3 deposits in 14 children, minimal change disease in four children, membranous GN in one patient, crescent GN in two children, and glomerulosclerosis with C3 deposits in one child. Oral steroids (nephrosis regiment) were prescribed in 40%. Meanwhile, intravenous methylprednisolone (1g/1.73m2 three days in a row) and cyclophosphamide (500 mg/m2/month for six months) was indicated in severe cases (respectively 23% and 9.6% of cases). All our 83 children had a good prognosis, and no cases of chronic kidney disease were noted at follow-up. PI-AGN is still very common in Morocco, mainly because GABH-streptococcus upper respiratory tract infections are still frequent in our children. However, the prognosis remains good if the appropriate management is started early.

POS-137 PREDICTIVE FACTORS OF CHRONIC KIDNEY FAILURE IN POST-INFECTIOUS ACUTE GLOMERULONEPHRITIS IN ADULTS

Post-infectious acute glomerulonephritis (post-infectious GNA) is an acute glomerulonephritis resulting from an immunological reaction secondary to an infection. It presents clinically as an acute nephritic syndrome with macroscopic or microscopic haematuria, proteinuria, oedematous syndrome, arterial hypertension and renal failure. Post-infectious GNA is frequent in children with favourable evolution, but in adults the evolution is uncommon. We conducted a retrospective descriptive and analytic study; on data from 54 patients diagnosed with post-infectious GNA between 1980 and 2020. The median age was 37.5 years (minimum=15 years, maximum=65 years), the sex ratio was 4.4. The percentage of patients with a history of diabetes was 7,4%, hypertension 7,4%, history of recurrent angina 10%. Infection was noted in 31 of the patients with the most frequent site observed to be upper respiratory tract. The median creatinine and proteinuria of 24 hour on admission was 150 mmol and 2.6 g/24h respectively. All patients have benefited renal puncture biopsy which showed endocapillary and extracapillary proliferation in 22.5% of cases. The percentage of patients who presented a persistence of urinary sediment abnormalities during surveillance was 62.5% for hematuria and proteinuria at the urinary strip. It was noted that 25.9% of patients presented a persistence of proteinuria of 24 hours. The end-stage renal failure was noted in 7.5% of patients. In univariate analysis; the persistence of 24h proteinuria was a significant predictive factor of chronic renal failure (p=0.01). The most predictive factor for chronic renal failure in adults diagnosed with post-infectious GNA is the persistence of 24-hour proteinuria.

POS-136 ACUTE POST-INFECTIOUS GLOMERULONEPHRITIS IN ADULTS: EPIDEMIOLOGICAL PROFILE

Acute post-infectious glomerulonephritis is caused by a non-suppurative inflammatory reaction resulting from an immune response to an infection. we will study the epidemiological, clinical and paraclinical characteristics of acute post-infectious glomerulonephritis in adults