Can infection-related glomerulonephritis recur?

Infection-Related Glomerulonephritis Can Recur

Yes, infection-related glomerulonephritis can recur, particularly when patients are exposed to new infections or have persistent underlying infections that are not adequately treated. 1, 2

Epidemiology and Types of Infection-Related GN

Infection-related glomerulonephritis (IRGN) encompasses a heterogeneous spectrum of disorders:

• Poststreptococcal GN: The prototypical form, especially common in children
• Staphylococcal-associated GN: Increasingly common, especially in adults and elderly patients
• IgA-dominant infection-related GN: More common in older patients with staphylococcal infections
• Endocarditis-related GN: Associated with various bacterial pathogens
• Shunt nephritis: Can occur months to decades after shunt placement

Risk Factors for Recurrence

Several factors increase the risk of recurrence:

• Inadequate treatment of the initial infection 1
• Genetic background of the host's complement system 3
• Pre-existing kidney damage 4, 3
• Underlying diseases: Diabetes, liver cirrhosis, cancer, and other comorbidities 4
• Advanced age: Older patients have higher risk of recurrence and progression to chronic kidney disease 3

Diagnosis of Recurrent Infection-Related GN

Clinical Presentation

• Hematuria (microscopic or gross)
• Proteinuria (nephrotic or non-nephrotic)
• Hypertension
• Edema
• Reduced kidney function

Diagnostic Approach

1. Urinalysis: Look for glomerular hematuria and red blood cell casts 1
2. Laboratory tests:
   • Serum creatinine and eGFR
   • Complement levels (C3, C4) - typically low in acute phase
   • Culture evidence of infection
   • Specific antibody tests (anti-streptolysin O, anti-DNAse B)
3. Kidney biopsy: Gold standard for diagnosis 1
   • Particularly useful when culture evidence is elusive
   • Helps distinguish from other forms of GN
   • Assesses prognosis and guides therapy

Management of Recurrent Infection-Related GN

Primary Treatment

1. Antibiotic therapy: The cornerstone of treatment 1, 5

   • Target the specific causative organism
   • Complete the full course of antibiotics
   • For poststreptococcal GN: Penicillin or erythromycin (if penicillin-allergic) for 10 days

2. Supportive care:

   • Blood pressure control with ACE inhibitors or ARBs
   • Diuretics for edema management
   • Dietary sodium restriction (<2.0 g/day)
   • Protein restriction based on proteinuria level and kidney function

Special Considerations

• Immunosuppression: Generally avoided in infection-related GN 1

  • Consider only in rapidly progressive disease with crescents
  • Always control the infection before initiating immunosuppression

• IgA-dominant infection-related GN:

  • Must be distinguished from idiopathic IgA nephropathy
  • Avoid corticosteroids as they may worsen outcomes 1

• Monitoring:

  • Regular assessment of kidney function
  • Urinalysis to track hematuria and proteinuria
  • Complement levels (persistently low C3 beyond 12 weeks may indicate C3 glomerulonephritis) 1

Prognosis

Prognosis varies significantly based on several factors:

• Age: Children generally have better outcomes than adults 2, 4
• Underlying diseases: Patients with comorbidities have worse prognosis 4
• Histological findings: Interstitial infiltration on biopsy predicts incomplete recovery 4
• Type of infection: Staphylococcal infections generally have worse outcomes than streptococcal 2

Long-term studies show that even after apparent complete resolution, an episode of infection-related GN can be a risk factor for future chronic kidney disease 3.

Prevention of Recurrence

1. Prompt treatment of infections
2. Regular monitoring of patients with history of infection-related GN
3. Vaccination against common pathogens (pneumococcal, influenza) 5
4. Management of underlying conditions that predispose to infections

By addressing both the infectious trigger and providing appropriate supportive care, the risk of recurrence and progression to chronic kidney disease can be minimized.