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Saudi J Kidney Dis Transpl 2014;25(3):567-571

2014 Saudi Center for Organ Transplantation

Saudi Journal
of Kidney Diseases
and Transplantation

Original Article
Acute Post-infectious Glomerulonephritis in Adults:
A Single Center Report
Mouna Hamouda1,2, I. Mrabet1,2, N. Ben Dhia1,2, S. Aloui1,2, A. Letaif1,2, M. A. Frih1,2,
H. Skhiri1,2, M. Elmay1,2
1

Department of Nephrology, Fattouma Bourguiba Hospital, 2University Faculty of Medicine,

Monastir, Tunisia

ABSTRACT. Acute post-infectious glomerulonephritis (APIGN) is uncommonly seen in adults;

its incidence is progressively declining, particularly in developed countries. The aim of this study
was to evaluate the epidemiological, clinical and biologic features of APIGN in a Tunisian center.
A retrospective descriptive analytic study was carried out on 50 patients aged more than 15 years
who were admitted to the Monastir Hospital between 1991 and 2007, with a diagnosis of APIGN.
There were more males than females (66% vs. 34%), and the mean age of the patients was 36.8
10 years. Only 10% had an immunocompromised background, including diabetes. The most
common site of infection was upper respiratory tract, followed by skin and pneumonia. The most
common causative agent was Streptococcus (66%), followed by Staphylococcus (12%). 73.8% of
the patients had low C3 complement levels. The mean peak serum creatinine was 190 mol, and
4% of patients required acute dialysis. The patients were followed-up for a mean period of 18
months (range, 0.1697 months). During follow-up, of the 46 patients reviewed in the consultation, the majority showed complete remission, 12 patients had persisting abnormalities such as
hypertension in 17%, chronic renal failure in 8% and proteinuria in 6.5%, and one patient had
concomitant hypertension and chronic renal failure. Our study suggests that APIGN is still endemic in some parts of the world such as Tunisia, and our data showed a favorable prognosis in adults.
Introduction
Acute post-infectious glomerulonephritis
(APIGN) is an immunologically mediated
disease. In the recent decades, the prevalence
Correspondence to:
Dr. Mouna Hamouda,
Department of Nephrology,
Fattouma Bourguiba Hospital,
Monastir 5000, Tunisia
E-mail: mouuna121@yahoo.fr

of APIGN has tended to decline in most industrialized countries, but high rates persist in
some developing communities.1-3 The aim of
this study was to evaluate the epidemiological,
clinical and biologic features of APIGN in a
Tunisian center.
Patients and Methods
A retrospective descriptive analytic study was
carried out on 50 patients aged more than 15
years with the diagnosis of APIGN, who were

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568

admitted to the Monastir Hospital between

1991 and 2007. The medical records of all
patients were reviewed.
The diagnosis of APIGN was based on clinical manifestations, including hematuria, edema, hypertension and oliguria with a history of
recent infection. Laboratory findings such as
proteinuria, complement deficiency and increased serum creatinine were also reviewed.
The diagnosis of APIGN required positive
testing of recent group A-beta hemolytic
Streptococcal infection by either anti-streptolysin O antibody (ASO) or positive culture;
ASO was considered to be elevated at levels
>200 IU/mL.
The diagnosis of post non-streptococcal glomerulonephritis (GN) was made when organisms other than group A-beta hemolytic
Streptococcus were grown on culture, either
bacteria or non-bacterial organisms.

Hamouda M, Mrabet I, Ben Dhia N, et al

The clinical indications for renal biopsy were

rapidly progressive GN or familial nephritis,
and persisting azotemia. Data were collected
using hospital records on admission, hospital
progress notes and outpatient follow-up. Oliguria was defined as urine output <500 mL
over 24 h and anuria as urine output <100 mL
over 24 h.
Results
During the 17-year study period, 50 patients
presented with APIGN in accordance with the
inclusion criteria: 11 cases between 1991 and
1996, 21 cases between 1997 and 2003 and 12
cases between 2003 and 2007. The demographic and clinical data on this patient cohort are
presented in Table 1. There were more males
than females (66% vs. 34%), and the mean age
of patients was 36.8 10 years. Most patients

Table 1. Demographic data and clinical features of the study patients.

No.
Sex
Male
33
Female
17
Preceding infection
Not found
5
Skin only
15
Upper respiratory tract only
22
Skin and upper respiratory tract
2
Pulmonary
6
Season
Autumn
23
Winter
11
Spring
10
Summer
6
Reason for consultation
Fever
11
Abdominal symptoms
3
Headache
3
Direct symptoms of PIGN
33
Macroscopic hematuria
5
Edema
10
Oligo-anuria
10
Arterial hypertension
34
Delay between streptococcal infection and
13.5 8
symptoms, days (mean SD)
Duration of hospitalization
10 3
Mean age, years (mean SD)
36.8

PIGN: Post-infectious glomerulonephritis.

Percentage of patient cohort

66%
34%
10%
30%
44%
4%
12%
46%
22%
20%
12%
22%
6%
6%
66%
10%
20%
20%
68%

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Acute post-infectious glomerulonephritis in adults

were aged between 16 and 35 years (56%).

Only 8% of patients were older than 65 years.
Five patients (10%) had a history of diabetes
mellitus type-2. The site of infection was identified in 90% of the patients, the most common
site being the upper respiratory tract (44%),
followed by skin (30%), lung (pneumonia)
(12%) and associations of the upper respiretory tract and skin concurrently (4%) (Table 1).
The mean duration from clinical onset of
infection to renal disease was 13.5 8 days.
This delay was less than two weeks in 95.4%
of patients with upper respiratory tract infection, and more than three weeks in majority
(60%) of the patients with skin lesions. The
reasons for consultation were fever in 22%,
abdominal symptoms in 6% and headache in
6%. The majority of patients (66%) showed
direct signs of APIGN such as macroscopic
hematuria, edema, hypertension and oliguria.
At presentation, 68% of the patients had
hypertension, including severe hypertension in
16% of the patients (systolic arterial pressure
>180 mm Hg and/or diastolic pressure >110
mm Hg). Peripheral edema was present in 94%
of the patients. Sixteen percent of the patients
had oliguria and 4% had anuria.
The mean peak serum creatinine was 190
mol, the mean glomerular filtration rate (GFR)
at presentation was 37 mL/min and 4% of the
patients required acute dialysis. Twenty-four
patients (48%) had creatinine values >120
mol/L. Proteinuria was in the nephritic range
in 10% of the patients. The most common causative agent was Streptococcus (66%), followed
by Staphylococcus (12%). Testing for serum
complement (C) was performed in 42 patients,
of whom 73.8% had lowered C3 and 19% had
lowered C4.
Test for anti-neutrophil cytoplasmic autoantibody was performed in two patients having
rapidly progressive acute renal failure. The test
was negative in both cases. Test for serum
cryoglobulin was performed in three patients;
all had negative titers. The anti-nuclear factor
was looked for in seven patients, and was
negative in all.
Renal biopsy was performed in 16 patients.
In 12 patients (75%), histology showed endo-

569

capillary proliferation without any crescents

and with immunoglobulin G (IgG) and C3
fraction deposits. In two patients who presented with rapidly progressive renal failure,
renal histology showed features of extensive
extra-capillary proliferation (crescentic glomerulonephritis). In two other patients who presented with persistent macroscopic hematuria,
histology showed mesangial proliferation without IgA deposits.
The initial evolution was assessed using data
collected during the period of hospitalization
and at the end of the patients stay in the
hospital (mean of 10 days). Edema had resolved in 96% and hypertension in 90% of the
cases. Diuretic therapy (furosemide) had been
used in 74% of the patients for a mean of
seven days, and a second anti-hypertensive
drug had been administered to 66% of the
patients for a mean of five days.
Patients with known active infection were
treated with antibiotics. Penicillin G was given
to patients with Streptococcal infection (20%);
in patients allergic to penicillin, macrolides
were used. All patients with Staphylococcal
infection were treated with Oxacilin. The mean
GFR at discharge was 59 mL/min.
Patients were followed-up for a mean period
of 18 months (range, 297 months), until macroscopic hematuria, proteinuria, hypo-complementemia and renal impairment resolved.
Four patients were lost to follow-up and their
data could not be assessed. Hematuria resolved
in six months in 93% (43/46) and proteinuria
resolved before six months in 91% (40/46) of
the patients. The mean GFR at six months was
62 mL/min.
During follow-up, of the 46 patients reviewed,
the majority showed complete remission, while
12 patients had some residual abnormalities:
eight (17%) had hypertension, four patients
(8%) had chronic renal failure, three patients
(6.5%) had proteinuria and one patient had
concomitant hypertension and chronic renal
failure.
Discussion
Post-infectious GN is an immunologic res-

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570

ponse of the kidney to infection, commonly

triggered by Streptococci, although many other
organisms can cause the condition. GN occurs
primarily in children (aged 610 years) and
young adults, with a male predominance of 2
3:1.1,2,4 In recent years, affected patients in the
developed world, especially Europe and the
United States (US), tend to be adults. Individuals with co-morbidities such as diabetes and
alcoholism are at an increased risk of developing the disease; one-third of individuals
with APIGN have one or two of these comorbidities.3,5 This finding is in contrast to
reports published between 1960 and 1980, in
which most of the affected patients had no
notable medical history.6,7 The changes in the
pattern of APIGN have not been clearly delineated; improvement in socio-economic status
and living standards of many communities and
the widespread and early use of antibiotics
may be responsible, at least in part.3 In our
study, there were more males than females and
10% had an immunocompromised background,
including diabetes.
APIGN is a typical form of acute nephritic
syndrome and is characterized by hematuria,
proteinuria, edema and, often, by hypertension
and a mild degree of acute kidney injury. The
typical patient with APIGN is a child who
abruptly develops puffiness of the eyelids and
edema after infection, followed by smoky and
scanty urine and increasing blood pressure.
Anuria and nephrotic-range proteinuria are
sometimes observed.1,3,4 In our study, we observed anuria in 4% and nephrotic-range proteinuria in 10% of patients.
Urine volume usually increases four to seven
days after hospital admission, and this increase
is rapidly followed by resolution of edema and
normalization of blood pressure. Microscopic
hematuria takes several months to resolve, and
can persist for up to one year after the acute
attack.5,6
APIGN usually presents after Streptococcal
pharyngeal or skin infections, although other
suppurative infections (including acute bacterial endocarditis and pneumococcal pneumonia), protozoa and viruses have also been
linked to the disease.7-9 About 90% of the pa-

Hamouda M, Mrabet I, Ben Dhia N, et al

tients in our study had a known recent history

of previous infection involving the upper
respiratory tract or skin.
On rare occasions (4.6% of biopsy specimens), APIGN, especially the post-streptococcal form, is complicated by rapidly rising azotemia. Such cases are diagnosed as rapidly
progressive nephritic syndrome.10
A variety of infections have clinicpathologic
presentations that are similar to those of poststreptococcal GN. This suggests that a marked
overlap exists among the molecular and cellular responses to these pathogens.11 This also
indicates that no single antigen is the sole
cause of post-streptococcal GN in all patients.
Individual susceptibility, possibly determined
by the hosts genetic factors, might have a
huge influence on the pathogenicity of the
precipitating organism.12
Treatment of APIGN is mainly supportive
unless recovery of renal function fails to occur
despite eradication of the causative organism.5,6 The prognosis of patients with APIGN
is largely influenced by the specific presentation and histopathology. Crescentic glomerulonephritis and the garland immunofluorescence pattern carry a poorer outcome than
other pathologic patterns. However, other factors such as age, type of pathogen and coexisting diseases, including diabetes and cardiovascular, influence the prognosis.13,14
In general, chronic renal failure resulting
from APIGN is exceptional. The group of patients with especially poor long-term prognosis
is elderly patients who develop persistent proteinuria in the nephrotic range; 77% of these
patients develop chronic renal failure.15-20
Conclusion
APIGN is still endemic in some parts of the
world such as Tunisia. Our data showed a
favorable prognosis in the study patients, but
severe systemic complications are possible
because of sodium and water retention in the
acute phase. APIGN can be potentially prevented with early antibiotic treatment.

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571

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