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Kidney non-tumor

Primary glomerular diseases

Post-infectious glomerulonephritis


Reviewers: Nikhil Sangle, M.D. (see Reviewers page)
Revised: 17 March 2014, last major update July 2012
Copyright: (c) 2003-2012, PathologyOutlines.com, Inc.

General
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● Also called post-streptococcal or acute glomerulonephritis; a type of diffuse endocapillary proliferative glomerulonephritis

Pathophysiology
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● Deposition of immune complexes from antibodies against organisms elicits acute inflammatory response and nephritic syndrome
● Associated with nephritogenic strains of Streptococcus pyogenes (beta hemolytic Strep group A)
● Similar histologic findings also associated with endemic malaria, toxoplasmosis, hepatitis B/C, HIV, varicella, spirochetes, staphylococci (Clin J Am Soc Nephrol 2006;1:1179), meningococci and other bacteria
● Similar process occurs in response to endogenous antigen in SLE


Diagram


Clinical features
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● Post-streptococcal disease is decreasing in US (eMedicine)
● 95% recover with conservative therapy; 1% develop rapidly progressive glomerulonephritis, 1-2% develop chronic glomerulonephritis
● Poor prognosis more likely if massive proteinuria and abnormal GFR; 2-5% die from pulmonary edema, hypertensive encephalopathy or crescentic glomerulonephritis; children with obesity may have greater renal injuries (Clin Nephrol 2009;71:632)
Children age 6-10: nephritic presentation with abrupt onset of hematuria, oliguria, fever, malaise and nausea 1-4 weeks after strep infection of pharynx or skin (impetigo); RBC casts, proteinuria, periorbital edema and hypertension
Adults: may have atypical presentation with sudden hypertension, edema and elevated BUN; 60% recover, others develop rapidly progressive glomerulonephritis (Arab J Nephrol Transplant 2012;5:93, J Med Assoc Thai 2006;89 Suppl 2:S157)
Laboratory (children and adults): high antistreptococcal antibody titers, low C3 (due to consumption)

Subclinical:
● Typical immune complex deposition of clinical disease, but with minimal symptoms or urinary abnormalities
● Important to recognize, since present in 10% of renal biopsies (Hum Pathol 2003;34:3)

Case reports
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● 6 year old girl and 12 year old boy with simultaneous occurrence with hemolytic uraemic syndrome (Eur J Pediatr 2001;160:173)
● 11 year old boy with sinus related orbital abscess (Arq Bras Oftalmol 2008;71:579)
● 42 year old male kidney transplant recipient with Salmonella infection (Clin Nephrol 2007;67:321)
● 4 year old boy with adenovirus infection (Isr Med Assoc J 2009;11:758, free full text)

Micro description
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● Glomeruli are globally and diffusely enlarged and hypercellular due to neutrophils and macrophages and proliferation of mesangial and endothelial cells (also called ‘exudative’ glomerulonephritis)
● Swelling of endothelial cells and presence of inflammatory cells obstructs capillary lumina
● Returns to normal within months
● Slight mononuclear leucocytic infiltrate and edema in the interstitium
● Tubules contain red blood cells

Micro images
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Various images

       
Markedly hypercellular glomeruli due to neutrophils

Immunofluorescence
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● Lumpy-bumpy (granular) deposition of IgG, IgM and C3 in peripheral glomerular loops
● Also properdin; no C1q or C4

Immunofluorescence images
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Lumpy bumpy (granular) or starry scar immunofluoresence


A: light microscopy shows glomerular lobular accentuation, endocapillary cell proliferation and neutrophils, but no immune complexes
B: fluorescence microscopy shows deposits corresponding to immune complexes bulging from outer surfaces of glomerular capillary loops


Electron microscopy description
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● Subepithelial ‘humps’ (finely granular, dome-shaped, electron dense, representing immune complex deposits), no spikes (compare to membranous glomerulonephritis)
● Obliteration of epithelial cell foot processes
● Subepithelial, intramembranous, subendothelial and mesangial deposits in the acute phase

Electron microscopy images
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Subepithelial deposits

End of Kidney non-tumor > Primary glomerular diseases > Post-infectious glomerulonephritis

Ref Updated: 5/29/12


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