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Clinical profile and outcome of Acute Glomerulonephritis in a Tertiary Care

Centre in the Eastern Nepal

Article  in  Journal of the Institute of Medicine · April 2014

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Shankar Prasad Yadav Gauri Shankar Shah

B.P. Koirala Institute of Health Sciences B.P. Koirala Institute of Health Sciences
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 Original Article 29

!"#"$%!&'()*!+&%#,&-./$)0+&)1&2$./+&3!)0+(.!)#+45("/"6&
in a Tertiary Care Centre in the Eastern Nepal
Shah GS and Yadav SP
DepartmentofPediatricsandAdolescentM edi
cine,B.P.KoiralaInst
ituteofHeal
thSci
ences,Dharan,Nepal
Correspondence to: Dr .GauriS Shah,Professorand Head,Depart
mentofPedi
atri
csandAdol
escentM edi
cne,B.P.
KoiralaInstituteofHealthSciences,Dharan,Nepal
.
E- mail: gaurishankarshah@ live.
com

Abstract
Introduction: Acute glomerul onephri t
is (AGN)general ly present
s as a const ellati
on of
!"#!$%&'()'&#!*+,"-%&(-.)',/#)0&-"-.)0&)!"&12'-!&(34-/'-!%#1!5&6(-&%',"3&)#.-"&'1&"-'-/.#!-&
'(-& *+#!#*178#1*(-.#*)+& 4/1 +-& )!"& 1,'*1.-& 12& )*,'-& $+1.-/,+1!-4(/#'#%& #!& *(#+"/-!& )'& )&
tertiarycarecentreintheEasternPartofNepal .
Methods: A prospective study was conduct ed on all t he cases found t
o have acute
glomerulonephritis,and sample si
ze consti
tuted allchildren between 1 monthto 15 year,
attendingtheRenalSpecialOPD andt hosehospitalizedinpedi atri
cdepartmentofBPKIHS
from Feb.2012 toJan.2013wi thacutegl omerulonephritis.
Results: Thereweretotalof94casesofacut eglomerul onephri ti
s(AGN),whi chcompri se
3.1% ofannualpediatricadmissions.52. 1% werefemal eandmal ewere47. 8%.M eanageof
presentationwas9. 2 yrs.±3. 1SD.Aet iologyofAGN wasposti nfect
iousgl omerul onephri t
is
(PIGN)84. 0%,lupus nephrit is 10.6%,mumps nephri tis 3.1% and HSP nephri tis 2.1%.
ASO titerwasraised in 34. 0%.47. 8% had rai sed urea,43. 6% had raised creat ini nel evel,
9:;4/1'-#!,/#)&<)%&4/-%-!'&#!&:=5=>&)!"&43,/#)&#!&?@5A>5&6(-&*1..1!&*+#!#*)+& !"#!$%&)'&
presentation weremicroscopichemat uria(95.7%),hypert ension (86.2%),edema(85. 1%),
fever(63. 8%),oliguria(22. 3%),pai n abdomen (21. 3%)and others.Hi story ofsoret hroat
andpyodermawaspresentin25. 5% and19. 1% respecti vely.Compli cationsatpresent ati
on
were hypertensive encephalopat hy (9.5%),cardiac fai lure (9.5%)and acut e kidney i njury
(6.3%). Of94 cases,92 cases(97. 8%)i mproved and 2 cases(2. 1%)expi red dueto acut e
kidneyinjury.
Conclusion: B*,'-& $+1.-/,+1!-4(/#'#%& #%& )& %#$!# *)!'& /-!)+& 4/18+-.& #!& *(#+"/-!& )!"& #%&
1!-& 12& '(-& *1..1!& *),%-%& 12& (1%4#')+& )".#%%#1!5& C)/+3& #"-!'# *)'#1!& )!"& *1.4/-(-!%#D-&
monitoringandmanagementisrequi redt opreventmorbi di tyandmort al it
y.
Key words: Children,hematuri
a,Acut
egl
omerul
onephrit
is

Introduction
Acute glomerulonephritis(AGN)generally present sasa /-%,+'&#!&$+1.-/,+)/&#!E)..)'#1!&)!"&#!F,/351,2 AGN may
*1!%'-++)'#1!& 12& !"#!$%& '()'& #!*+,"-%& (-.)',/#)0& -"-.)0& be isol ated tot he ki dney (primary glomerul onephriti
s)
and often hypertension.Although thepathogenesi si snot or be a component of a syst emic di sorder (secondary
fullyunderstood,currentevidencesupportsthatmostcases glomerul onephrit
is). Al t
hough Post st reptococcal
ofAGN areduet o an immunol ogicresponset o avari ety glomerul onephrit
is (PSGN) cont inues to be t he most
ofdifferentetiologic agents.The immunologi c response, common cause ofAGN gl oball
y,i tprimari ly occurs in
in turn,activates a numberofbiologicalprocesses t hat devel opi ngcountries.Oft heesti
mat ed470, 000new annual

)*)*),+-./01+ 2/01+ 34 



     
   
    
!"#$&%'( #
29-33
30 Shah GS et al.,

casesofPSGN worldwide,97percentoccuri ndevel

opi
ng AGN asshown i n Figure 1,wasPIGN i ncludi ng PSGN
countries,with an annualincidence thatrangesfrom 9.5 84. 0%,l upus nephri tis 10. 6%,and HSP nephri tis 2. 1%.
3,
4
to 28.5 per100, 000 individuals. The risk ofPSGN is Among PIGN,PSGN was34. 0%,mumpsnephri t i
s3. 1%
5
increasedin childrenbetween5 and12 yearsofage. and in remai ni ng the aeti ology could notbe det ermined.
J+#!#*)+& !"#!$%&)'&'(-&'#.-&12&4/-%-!')'#1! (Tabl e2)were
Methods hypert ension 86. 2%,edema 85. 1%,fever 63. 8%,gross
Thiswasaprospectivestudyconductedoveroneyearfrom hemat uria 41. 5%,oli guri a 22. 3%,pai n abdomen 21. 3%,
February 2012 to January 2013.Allthe casesi n the age dyspnea 11. 7%,encephal opat hy 10. 6% and j oint s pain
group of1 month to 15 years,reporting to pedi atricrenal 10.6%.Hi st
oryofsoret hroatandpyodermawaspresenti n
clinic and /oradmitted to pediatric wards, with features 25.5% and19. 1% respect ivel y.Uri neanal ysis(Table1)at
suggestiveofrenalsystem involvementweresubj ected to present at
ionshowedhemat uri ain95. 7%,prot einuri a(>2+)
adetailed history,clinicalexamination and investi gati
ons #!&??5K>0&4/1'-#!,/#)&LM:;N&#!&==5A>0&)!"&43,/#)&#!&?@5A>5&
anddatawererecordedinapre-designedproforma.Those Thusi nnephri tishemat uriai salmostalwaysaccompani ed
casesfoundtohaveacuteglomerulonephritiswerei ncluded by somedegreeofprot einuri aand i n somecasesthereis
and restwasexcl uded from thestudy.Thei nvest igati
ons pyuria.UTIwaspresenti n5. 3%,t hecul tureisol ateswere
included hemoglobin, total and differenti al leukocyte E.coli1%,st reptococcus 2. 1% and aci net obact er 2. 1%.
counts,ESR,grossand microscopicexaminat ion ofurine Anemi aasperW HO referenceval uewaspresenti n91. 4%.
and culture,24 hrurinary protein, serum t otalprotei n, Renalfunct ionwasi mpai redi nal mosthal foft hepat ient.
albumin,cholesterol,urea,creat inine,sodium,pot assium, Hi gh urea wasfound i n 47. 8%,si milarly creat i
ni ne was
calcium andphosphate.Serum Antistreptolysi nO,C3,C4, high in 43. 6%.El ect rol yteswere al so deranged i n some
ANA and anti-Ds DNA were done wherever i ndi cated. cases.Hponat remia (<135 meq/ L)was presenti n 4. 2%
Radiologicalinvestigations included ultrasonography of and hypernat remi a (>145 meq/ L) i n 12. 7%. Si mi larly
kidney,ureterandbl adder. hyperkal emi a(>5 meq/L)wasseeni n10. 6% andremai ni ng
werenormokal emic.ASO t itrewasrai sedi n34. 0%.About
Acute glomerulonephritis were categorized as post 31% caseswi th AGN also present ed wit h compl i
cati ons
infectious glomerulonephritis (PIGN), whi ch i ncluded ofwhi ch hypert ensiveencephal opat hy and cardi acfai lure
post streptococcal glomerulonephritis (PSGN), mumps 9.5%.Ot her compl icat ions were acut e kidney i njury i n
nephritisand otherinfectiousaetiology.Ot hercausesof 6.3% and nephrot i
crangeprot einuri a5. 3%.Al lthecases
AGN included lupus nephritis and Henoch Schonl ein were managed as per t he hospi talprot ocol,98% cases
4,/4,/)&!-4(/#'#%5&BGH&<)%&"- !-"&)!"*)'-$1/#I-"&,%#!$& improved and 2% expi red.Expired caseswerethosewho
%')!")/"&"- !#'#1!%56-8Theyweretreatedasperourhospi tal present edwi thacut eki dneyi njury.
protocols.Each patientwasfollowed during hospi talst ay
and was keptunderregularfollow up in pedi atric renal
clinic for their future course.The study protocol was
approvedbyInstit uteEthicsCommittee.Informedwri tten
consentwastakenfrom parentorauthorizedrepresent ative
ofeachpatient.

Statistical analysis
The data were analyzed using SPSS 20. 0 versi
on.
Descriptiveanalysiswasmadeusingcount,mean,median,
range,proportion,percentageandstandarddevi
ati
on.

Results
There were totalof94 casesofacute glomerulonephrit
is
(AGN),comprising 3. 1% ofannualpediatri
cadmissions.
Asshown in Table 1,52. 1% werefemaleand mal ewere Figure 1 Aetiology acute glomerulonephritis
47.8%,with almostequalfemale and male proport ion.
M ajority ofthecases,91.5% wereabove5 years(school
going age),age range was from 3 to 14 years.M ean
age ofpresentation was9. 2 yrs.± 3.
1 SD.Aetiology of

5*5*5,6789:16 ;9:16 <= >?@AB

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!"#$%&'%(#)*)+!#%,-./#$%.0%%1#.2$-3#.*$45-)6)7%89:;<= Discussions
!"#"$%!&'()1"!+&)1&3!)0+(.!)#+45("/"6&
Y[Z\] \^_a`] b c_db ^c e] `fg`hi^j k
`] ^`ha_a\l` Acut e gl omerulonephri tisi s one of t he common renal
probl emsencounteredi npaedi atricemergencyorout pati
ent
Common Age Group (5-15)yrs 87 91.5% clinic.Gl omerul onephri t
s (GN)typi cally presents as t he
m,nop*qsrn,tvuw xuy
z
{,|w }|s~
 €opirn,‚ | ƒ }„y
z …† sudden onsetofhemat uria (eithergross ormi croscopi c)
<#'(&1/&<#'(1,'&4/1'-#!,/#)0&"-*/-)%-"&$+1.-/,+)/& +'/)'#1!&
Sex
rate,and ret ention ofsodium and wat er,whi ch usual ly
Mal
e 45 47.87 % resultsi nanelevatedbl oodpressureandedema.Inchildren,
Femal
e 49 52.12 % themostcommoncauseofacut eAGN i spost streptococcal
9-11
th GN. Acutenephri t
isalsohasbeenassoci atedwit hother
Hypertensi
on (>95 Centi
le) 81 86.17 %
‡z ˆ pn[q,pio‰ y …ˆ … infectious agents (PIGN).Othercauses ofAGN i nclude
!"#$%&'()* 136 66.01% secondary GN (eg, Henoch-Schönl ein purpura [HSP],
>2+ (protei
n) 70 33.98% nephri tisassociated wit h subacut e bacteri
alendocardi tis,
Hematuri
a 90 95.74%
and shuntnephri tis).
In addi t
ion,severalcausesofchroni c
GN may presentasacut enephrit issyndromeand may be
Pyuri
a 32 34.04%
initi
al l
yi ndist
inguishabl e clinical l
y from acute disorders.
€npio‰Š‹ipŒaˆ Žipn…
These chroni c condi ti
ons i nclude primary GN (eg,IgA
Hi
gh Urea 45 47.87% nephropat hyandmembranoprol iferati
veGN [M PGN])and
secondaryGN (e. g.,lupusnephri t
is).
Hi
gh Creati
nine 41 43.61%
 Ži‘“’‰ ˆ Œoaˆ Žpi…,o’izn…npdoaˆ Žp In the devel oped count ries Acute posti nfectious (most
often postst reptococcal )GN hasal mostbeen wiped out
Acute Ki
dneyInj
ury 6 6.38 %
buti n Asi ai ncludi ng Nepal ,i tstillaccount sfora large
Cardi
acfai
lure 9 9.57 % numberofcases. 12
GroupA st rept ococcaldiseasesaremore
Encephal
opathy 9 9.57 % common i n chi ldren t han i n adul t
swi t
h diseasesrangi ng
Nephroti
crange protei
nuri
a 5 5.31 %
from pharyngi ti
sand i mpet igo to invasi ve i
nfect ionsand
thepost -st
rept ococcalsequel ae:acut erheumat icfeverand
13
acute post -streptococcal gl omerulonephri t
is. We found
Table 2: Signs and symptoms at presentation Tabl
PeI2.Si
GN g
nn84
i sa.0nd so
%, yfmwh
pto
im
chsa a
btout40% ofthe caseswere
pr
esent ati
on
S.
No. Sym pt
om s Num ber(% ) PSGN, 4% weremumpsandremai ninginfectiousaet i ology
wereprobabl yunknownvi ralaet i
ology.Lupusnephri tisand
1 Fever 60 (63.
8% ) HSPnephri tiswere10. 6% and2. 1% respect i
vel y.Si mil arly
inastudybyA. Y.El zoukietal ,inEast ernLi bya,t hemaj or
2 Edem a 80(85.
1% )
renaldi seaseswerepost -strept ococcalgl omerul onephriti s
14
3 Hem at
uri
a 39(41.
5% ) (116of343renalcasesoverast udyperi odof2 yrs).

4 Ol
igur
ia 21 (22.
3% ) In a study by Zhongguo 15. 8% as HSP nephri tis,and
15
7.3% has hepat iti
s B vi rus-associated nephrit is. We did
5 Pai
n abdom en 20 (21.
3% ) !1'& !"& )!3& !-4(/#'#%& )%%1*#)'-"& <#'(& (-4)'#'#%& #!& 1,/&
study.In our st udy al mostequalproporti on of female
6 Dysur
ia 4(4.
3% )
and mal e were affected (1. 08:1),howeveri n a st udy by
7 Sor
ethr
oat 24(25.
5% ) Anochi eI16 maleweremorewit h mal et o femal erat io of
(1.1:1),t
heproport ion ofmal ewasst illhigheri n astudy
8 Pyoder
ma 18 (19.
1% ) by M alla K17wi t
ht he rat io 1.6:1.The reasons for thi s
18
gendervariationsarenotknown. Asinot herstudies, most
9 Dyspnea 11 (11.
7% ) childrenwereschoolgoi ngagegroup.
10 Encephal
opat
hy 10 (10.
6% ) Common modes of present ati
on of AGN were gross
11 Joi
nts pai
n 10 (10.
6 %)
and mi croscopic hematuria (96%), pyoderma (19%),
encephalopathy (11%), hypert ensi
on (86%), oedema
12 BP (>95 t
h
Cent
il
e) 81 (86.
2 %) (85%) and ol iguri
a (22%). 30% of AGN presented
with compl icati
ons commonest being hypert ensive
encephalopathy (10%),followed by CCF (9%)and AKI
(6%). OchekeIE19 document s hypert
ension (92.3%) as
commonest present ati
on foll
owed by oli guria (88.
5%),
Edema (84. 6%), Hypertensive encephalopathy (23.1%)

)*)*),+-./01+ 2/01+ 34 



     
   
    
!"#$&%'( #
29-33
32 Shah GS et al.,

!"# $$%&'()*+# ,-.# /!"0!12# 2311.24# 4- 4# 56".2# 67# References

presentation though similar, our study showed relatively
lower complications rate at presentation.UTI was present 1. Chadban SJ, Atkins RC. Glomerulonephritis. Lancet
in 5.3%, the culture isolates were E.coli 1%, streptococcus 2005; 365: 1797.
8
2.1% and acinetobacter 2.1%. In the study by Malla K 17% 2. Couser WG. Pathogenesis of glomerulonephritis.
has associated UTI. AGN complicated by UTI was also Kidney IntSuppl 1993; 42: S19.
observed in 20% cases in a study in Nigeria.20
3. Carapetis JR, Steer AC, Mulholland EK, Weber M.
Anochie I16found UTI in 22.6% patients; klebsiella being The global burden of group A streptococcal diseases.
the commonest organism isolated. We thus have less Lancet Infect Dis 2005; 5: 685.
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4. Rodriguez-Iturbe B, Musser JM. The current state
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elevated urea and creatinine in 47.8% and 43.6% SocNephrol 2008; 19: 1855.
respectively. Malla K17 noted that impairmentof urea was
seen in 56% and impairment of creatinine in 41%, which 5. Blyth CC, Robertson PW, Rosenberg AR. Post-
was almost similar to our study. Renal impairment observed streptococcal glomerulonephritis in Sydney:a 16-year
in another study was 33.3% and 5.5% respectively.21 ASO retrospective review. J Paediatr Child Health 2007;
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22,23
titre was observed upto 50%.
6. Kliegman RM, Stanton BF, St. Geme III JW, Schor NF,
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symptomatically and all the available supportive measures Textbook of Pediatrics. 19th ed. Philadelphia:Elsiever
were provided. Majority of the cases 98% improved, the Saunders; 2011:1778-1864
results are almost similar in comparison to other studies.16,17
7. Mishra OP, Prasad R, Singh UK. Disorders of kidney
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laboratory and pathology back up are major constrains
8. !"#$% &'()(*+'% ,-+*.*/% #0(1/'()/% 23-% 4*05/% (1)/6%
in developing countries for further workup. Hence the
")70-68%!/9)(.3)%+)1%*'+::(9*+.3)%32%4 ";% (1)/6%")5%
!"#$%&'!$()*+&,"!-+-) !./*)"!')01)%&*1)+")'21-1) &-1-3)
<=0>>'?%@AB@C%@8%BDEFG
However a good outcome from our study suggests that
early admission and meticulous treatment in majority of 9. Rodriguez-Iturbe B. Postinfectious glomerulonephritis.
the cases minimizes the fatal outcome. Am JKidney Dis 2000; 35:XLVI.

Conclusion 10. 4. Zhang Y, Shen Y, Feld LG, Stapleton FB. Changing

In conclusion, AGN is a common renal disease requiring
hospital admission in school going children in eastern
region of Nepal. They often have atypical presentations,
hence early diagnosis and prompt management are required
for better outcome. Adverse outcomes can be annulled
with more detailed laboratory and diagnostic methods
which are limited at present. Renal biopsy in complicated
cases not improving by supportive measures is mandatory,
especially in allowing rational use of corticosteroids and
other immunosuppressive drugs. Lack of specialised
1"'$1-)&"*)#"&" +&//()*14$+5&'+!")&$1)&)%&6!$)*$&70& 8-)
in a developing country settings. Nevertheless, as majority
of cases improves with symptomatic treatment and careful
-.44!$'+51) &$19)+')+-)6.-'+#1*)'!),+51)'21)01"1#')!:)'$1&'%1"')
to these patients before considering advanced diagnostic
procedures.
pattern of glomerular disease at Beijing Children’s
Hospital. ClinPediatr (Phila)1994; 33:
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The Management Of Glomerulonephritis. Introduction.
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13. Steer AC, Danchin MH, Carapetis JR. Group A
streptococcal infections in children. JPaediatr Child
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14. A.Y. Elzouki, F. Amin, and 0.P. Jaiswal. Prevalence
and pattern of renal disease in eastern Libya. Archives
of Disease in Childhood. 1983;(58):106-109.

!"#$%&'!(')"&*+*,&- None declared

”*”*”,•–—˜™1• š˜™1• ›œ žŸ ¡

¢£ž¤¥ ¡¦§ ¨§ Ÿ§ ©ž¤ª©«¨¬ ¨ ¡
© ­P®
¯ ¨ £ ­
°±²³­
´µ¶ ² 29-33
 !"#$%&'()$*"'(+$,-*.#./ 33

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Characteristics Of 1,316 Children With Renal Disease
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;**+"< < 9) =!#.//&2) < 9
) 1') &/3) ='.*+1-) !") /+"+ &/)
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22. Travis LB:Acute postinfectious glomerulonephritis.
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585-8.

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