今日の臨床サポート

急性腎炎症候群(小児科)

著者: 張田豊 東京大学 生殖・発達・加齢医学専攻 小児医学講座

監修: 五十嵐隆 国立成育医療研究センター

著者校正/監修レビュー済:2019/06/06
患者向け説明資料

概要・推奨   

薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
張田豊 : 特に申告事項無し[2021年]
監修:五十嵐隆 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行なった。溶連菌感染後の抗生剤の使用について加筆修正を行なった。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 急性腎炎症候群は、急性に発症する血尿、蛋白尿、高血圧、糸球体濾過率の低下およびNaと水分の貯留(浮腫)を来す症候群である。(図<図表>
  1. ほとんどが急性糸球体腎炎によるものであり、その大部分(8~9割)はA群β溶連菌の感染が原因である。上気道感染後に平均10日間、皮膚感染後には約2週間の潜伏期間をおいて発症する。(図アルゴリズム)急性溶連菌感染後糸球体腎炎(APSGN)は対症療法が主であり、乏尿期には塩分制限(3~5g/日)、飲水制限を行う。浮腫が著明な場合は利尿薬を用いる。自然治癒することが多い。
  1. 高血圧が持続する場合は、降圧薬(Ca拮抗薬、α1遮断薬、アンジオテンシン変換酵素[ACE]阻害薬、アンジオテンシンⅡレセプター拮抗薬など)を併用する
  1. 大部分は回復するが、重症例や遷延化する症例に対しては、慢性腎炎の急性増悪との鑑別が必要であり、腎生検が必要となる。
  1. いったん急性腎炎が治癒したのちも尿異常の再発が数割の患者にみられるため、フォローアップが大切である。
 
  1. 溶連菌感染後糸球体腎炎の疫学
  1. 先進国での溶連菌感染後糸球体腎炎は変化している。1960年代に比べ、罹患年齢が上昇し、罹患頻度が減少、軽症例が増加している。以前は溶連菌による膿皮症が原因の大半であったが、近年では大半が咽頭炎を契機としている。社会経済的な環境の変化がその原因と考えられている[1]
問診・診察のポイント  
  1. 先行感染後、コーヒー残渣様の肉眼的血尿、浮腫などで発症することが多い。高血圧脳症などで発病する場合や蛋白尿と浮腫が著明でネフローゼ症状により診断される場合もある。

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文献 

著者: Mohammad Ilyas, Asad Tolaymat
雑誌名: Pediatr Nephrol. 2008 Jul;23(7):1101-6. doi: 10.1007/s00467-008-0778-1. Epub 2008 Mar 29.
Abstract/Text The objective of this study was to review the epidemiological patterns of acute post-streptococcal glomerulonephritis (APSGN) in a pediatric population. We compared incidence, pathogenesis, clinical presentation and outcomes in two APSGN pediatric patient cohorts in northeastern Florida. Retrospective medical records were reviewed of children who were admitted to our institution with a diagnosis of APSGN. Patients admitted between 1999 and 2006 (recent cohort) were compared with a previously reported cohort of patients admitted between 1957 and 1973 (earlier cohort). The recent cohort comprised 45 children with APSGN of whom 87% were male and 13% were female; the median age was 7 years, and there was an average incidence of 6.4 patients per year. The earlier cohort comprised 153 children with APSGN of whom 62% were male and 38% were female; the median age 4.25 years, and there was an average incidence of 10.9 patients per year. The recent cohort was predominantly White-American (62%) and the earlier cohort predominately African American (87%). In the recent cohort, 64% of patients had antecedent pharyngitis, and in the earlier cohort, 66% of patients had antecedent pyoderma. In the recent cohort, 11% of APSGN cases occurred between August to October, and in the earlier cohort, 50% occurred during these months. In the recent cohort, symptoms of APSGN at presentation were milder and all cases recovered, but in the earlier cohort two deaths (1.3% mortality) were reported. In conclusion, there has been a decline in the incidence and severity of APSGN at our institute in recent decades. Pharyngitis has replaced impetigo as the predominant cause of APSGN. The etiological agent for impetigo has changed over the last decade, which has impacted the incidence, racial distribution, seasonal variation and severity of APSGN.

PMID 18373105  Pediatr Nephrol. 2008 Jul;23(7):1101-6. doi: 10.1007/s0・・・
著者: G A Cu, S Mezzano, J D Bannan, J B Zabriskie
雑誌名: Kidney Int. 1998 Sep;54(3):819-26. doi: 10.1046/j.1523-1755.1998.00052.x.
Abstract/Text BACKGROUND: We have previously demonstrated the preferential secretion of streptococcal proteinase or streptococcal pyrogenic exotoxin B (SPEB) by nephritic strains of Group A streptococci isolated from the skin or throat of patients with acute poststreptococcal glomerulonephritis (APSGN).
METHODS: To further explore the possible role of SPEB in APSGN, we performed ELISA studies to detect anti-SPEB antibodies in the sera of patients with APSGN, acute rheumatic fever (ARF), scarlet fever (SF) and normal children. Using ELISA, anti-SPEB titers on acute and convalescent APSGN sera were measured to determine immunity to APSGN. We also performed immunofluorescence studies on APSGN and non-APSGN kidney biopsies to probe for the presence and localization of SPEB.
RESULTS: Our data show that anti-SPEB antibodies are present in APSGN sera and antibody titers are significantly higher than in ARF, SF and normal sera. Anti-SPEB titers tend to rise acutely and decrease with time but do not reach baseline after one year. When kidney biopsies were probed with rabbit anti-SPEB antibody, 12 of 18 (67%) of the APSGN cases were positive while only 4 of 25 (16%) of the non-APSGN cases were positive.
CONCLUSIONS: In summary, we were able to demonstrate unique reactivity to SPEB in human sera and kidney biopsies of APSGN suggesting a significant role of this toxin in the pathogenesis of acute post-streptococcal glomerulonephritis.

PMID 9734606  Kidney Int. 1998 Sep;54(3):819-26. doi: 10.1046/j.1523-・・・
著者: Stephen R Batsford, Sergio Mezzano, Michael Mihatsch, Emile Schiltz, Bernardo Rodríguez-Iturbe
雑誌名: Kidney Int. 2005 Sep;68(3):1120-9. doi: 10.1111/j.1523-1755.2005.00504.x.
Abstract/Text BACKGROUND: Acute glomerulonephritis can follow infection by group A streptococci. An immune-complex pathogenesis is accepted, but the causative antigen(s) is still controversial. In recent years, 2 streptococcal antigens, the cationic cysteine proteinase exotoxin B (SPE B) and the plasmin receptor, a glyceraldehyde phosphate dehydrogenase (Plr, GAPDH) have attracted attention because: (1) they were localized in glomeruli in patients with acute post-streptococcal glomerulonephritis (APSGN); and (2) serum antibody to these antigens was associated with nephritogenic streptococcal infections. To date, putative nephritogens were always tested independently. Here, the relevance of SPE B and GAPDH was evaluated in the same renal biopsies and serum samples of well-defined APSGN patients.
METHODS: Renal biopsies (17 patients) and serum samples (53 patients) with APSGN and appropriate controls were examined. Immunofluorescent staining of frozen sections was performed using specific antibodies to SPE B and GAPDH. Serum antibodies were investigated by both enzyme-linked immunosorbent assay (ELISA) and Western blot methodology.
RESULTS: Glomerular deposits of SPE B were demonstrated in 12/17 APSGN biopsies, and 2 cases were borderline; circulating antibodies were found in all instances (53/53 patients). Glomerular deposition of GAPDH was detected in 1/17 biopsies, and 2 cases were borderline; circulating antibodies were found in 5/47 patients. In 31 control biopsies, only weak staining for each antigen was found in 2 cases.
CONCLUSION: In this study, glomerular deposits of and antibody response to zymogen/SPE B are more consistently present in APSGN than deposits and antibody response to GAPDH. Zymogen/SPE B is likely to be the major antigen involved in the pathogenesis of most cases of APSGN.

PMID 16105042  Kidney Int. 2005 Sep;68(3):1120-9. doi: 10.1111/j.1523-・・・
著者: Nobuyuki Yoshizawa, Kazuo Yamakami, Masayuki Fujino, Takashi Oda, Kikuko Tamura, Koichi Matsumoto, Tetsuzo Sugisaki, Michael D P Boyle
雑誌名: J Am Soc Nephrol. 2004 Jul;15(7):1785-93.
Abstract/Text The role of nephritis-associated antigen as a virulence factor for acute poststreptococcal glomerulonephritis (APSGN) remains to be fully clarified. Nephritis-associated plasmin receptor (NAPlr) was previously isolated from group A streptococcus (GAS) and shown to bind plasmin(ogen). The nucleotide sequence of the naplr gene from GAS isolates obtained from patients with APSGN was determined. The sequence of the putative open reading frame (1011 bp) showed 99.8% identity among isolated strains. Homology screen revealed an exact match with streptococcal glyceraldehyde-3-phosphate dehydrogenase (GAPDH). NAPlr exhibited GAPDH activity in zymography, and it activated the complement pathway in vitro. In APSGN kidney biopsy specimens, NAPlr was observed mainly in the early stage of the disease (1 to 14 d after onset) but was not colocalized with either C3 or IgG as assessed by double immunofluorescence staining. Sera of patients with APSGN, patients with GAS infection without renal involvement, nonrenal pediatric patients, and healthy adults as controls were assayed for anti-NAPlr antibody titers. Anti-NAPlr antibodies were present most frequently in APSGN sera, and antibody titers were also significantly higher than in patients with GAS infection alone or in other control patients. Moreover, antibody titers remained elevated during the entire 10-yr follow-up period.

PMID 15213266  J Am Soc Nephrol. 2004 Jul;15(7):1785-93.
著者: Mieke L van Driel, An Im De Sutter, Hilde Habraken, Sarah Thorning, Thierry Christiaens
雑誌名: Cochrane Database Syst Rev. 2016 Sep 11;9:CD004406. doi: 10.1002/14651858.CD004406.pub4. Epub 2016 Sep 11.
Abstract/Text BACKGROUND: Antibiotics provide only modest benefit in treating sore throat, although effectiveness increases in participants with positive throat swabs for group A beta-haemolytic streptococci (GABHS). It is unclear which antibiotic is the best choice if antibiotics are indicated.
OBJECTIVES: To assess the evidence on the comparative efficacy of different antibiotics in: (a) alleviating symptoms (pain, fever); (b) shortening the duration of the illness; (c) preventing relapse; and (d) preventing complications (suppurative complications, acute rheumatic fever, post-streptococcal glomerulonephritis). To assess the evidence on the comparative incidence of adverse effects and the risk-benefit of antibiotic treatment for streptococcal pharyngitis.
SEARCH METHODS: We searched CENTRAL (2016, Issue 3), MEDLINE Ovid (1946 to March week 3, 2016), Embase Elsevier (1974 to March 2016), and Web of Science Thomson Reuters (2010 to March 2016). We also searched clinical trials registers.
SELECTION CRITERIA: Randomised, double-blind trials comparing different antibiotics and reporting at least one of the following: clinical cure, clinical relapse, or complications or adverse events, or both.
DATA COLLECTION AND ANALYSIS: Two review authors independently screened trials for inclusion, and extracted data using standard methodological procedures as recommended by Cochrane. We assessed risk of bias of included studies according to the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions and used the GRADE tool to assess the overall quality of evidence for the outcomes.
MAIN RESULTS: We included 19 trials (5839 randomised participants); seven compared penicillin with cephalosporins, six compared penicillin with macrolides, three compared penicillin with carbacephem, one trial compared penicillin with sulphonamides, one trial compared clindamycin with ampicillin, and one trial compared azithromycin with amoxicillin in children. All included trials reported clinical outcomes. Reporting of randomisation, allocation concealment, and blinding was poor in all trials. The overall quality of the evidence assessed using the GRADE tool was low for the outcome 'resolution of symptoms' in the intention-to-treat (ITT) analysis and very low for the outcomes 'resolution of symptoms' of evaluable participants and for adverse events. We downgraded the quality of evidence mainly due to lack of (or poor reporting of) randomisation or blinding, or both, heterogeneity, and wide confidence intervals (CIs).There was a difference in symptom resolution in favour of cephalosporins compared with penicillin (evaluable patients analysis odds ratio (OR) for absence of resolution of symptoms 0.51, 95% CI 0.27 to 0.97; number needed to treat to benefit (NNTB) 20, N = 5, n = 1660; very low quality evidence). However, this was not statistically significant in the ITT analysis (OR 0.79, 95% CI 0.55 to 1.12; N = 5, n = 2018; low quality evidence). Clinical relapse was lower for cephalosporins compared with penicillin (OR 0.55, 95% CI 0.30 to 0.99; NNTB 50, N = 4, n = 1386; low quality evidence), but this was found only in adults (OR 0.42, 95% CI 0.20 to 0.88; NNTB 33, N = 2, n = 770). There were no differences between macrolides and penicillin for any of the outcomes. One unpublished trial in children found a better cure rate for azithromycin in a single dose compared to amoxicillin for 10 days (OR 0.29, 95% CI 0.11 to 0.73; NNTB 18, N = 1, n = 482), but there was no difference between the groups in ITT analysis (OR 0.76, 95% CI 0.55 to 1.05; N = 1, n = 673) or at long-term follow-up (evaluable patients analysis OR 0.88, 95% CI 0.43 to 1.82; N = 1, n = 422). Children experienced more adverse events with azithromycin compared to amoxicillin (OR 2.67, 95% CI 1.78 to 3.99; N = 1, n = 673). Compared with penicillin carbacephem showed better symptom resolution post-treatment in adults and children combined (ITT analysis OR 0.70, 95% CI 0.49 to 0.99; NNTB 14, N = 3, n = 795), and in the subgroup analysis of children (OR 0.57, 95% CI 0.33 to 0.99; NNTB 8, N = 1, n = 233), but not in the subgroup analysis of adults (OR 0.75, 95% CI 0.46 to 1.22, N = 2, n = 562). Children experienced more adverse events with macrolides compared with penicillin (OR 2.33, 95% CI 1.06 to 5.15; N = 1, n = 489). Studies did not report on long-term complications so it was unclear if any class of antibiotics was better in preventing serious but rare complications.
AUTHORS' CONCLUSIONS: There were no clinically relevant differences in symptom resolution when comparing cephalosporins and macrolides with penicillin in the treatment of GABHS tonsillopharyngitis. Limited evidence in adults suggests cephalosporins are more effective than penicillin for relapse, but the NNTB is high. Limited evidence in children suggests carbacephem is more effective than penicillin for symptom resolution. Data on complications are too scarce to draw conclusions. Based on these results and considering the low cost and absence of resistance, penicillin can still be regarded as a first choice treatment for both adults and children. All studies were in high-income countries with low risk of streptococcal complications, so there is need for trials in low-income countries and Aboriginal communities where risk of complications remains high.

PMID 27614728  Cochrane Database Syst Rev. 2016 Sep 11;9:CD004406. doi・・・
著者: S Roy, W M Murphy, B S Arant
雑誌名: J Pediatr. 1981 Mar;98(3):403-10.
Abstract/Text Crescenteric glomerulonephritis preceded by a streptococcal infection with creatinine clearance CCr of less than 30 ml/minute/1.73 m2 was treated by supportive care plus three months of quintuple therapy (prednisone, azathioprine, cyclophosphamide, dipyridamole, and heparin followed by warfarin) in five children (Group A) or by supportive care alone in five others (Group B). Of the glomeruli examined, 69.8 +/- 11.7% (mean +/- SE) in Group A and 64.4 +/- 10.6% in Group B had crescents which involved 54.0 +/- 10.8% and 60.0 +/- 10.5% of glomerular circumference, respectively. Clinical and histologic findings supported a recent streptococcal infection in every patient. Two patients from Group A had mild proteinuria and normal CCr at 12 months; one died abruptly of pulmonary hemorrhage after maintaining a normal CCr for 25 months. Following a second episode of poststreptococcal acute glomerulonephritis seven months after the first, one patient from Group B had persistent mild proteinuria for 41 months and hypertension through 56 months of follow-up. Nine surviving patients have maintained normal CCr for eight to 60 months (mean 29.5 months). The findings of this study suggest that this quintuple therapy offers no advantage over supportive care in the clinical management and outcome of children with severe crescenteric glomerulonephritis when an antecedent streptococcal infection is confirmed by serologic and histopathologic criteria.

PMID 7205449  J Pediatr. 1981 Mar;98(3):403-10.
著者: Marco Zaffanello, Luigi Cataldi, Massimo Franchini, Vassilios Fanos
雑誌名: Med Sci Monit. 2010 Apr;16(4):RA79-84.
Abstract/Text The majority of children with the epidemic form of acute post-streptococcal glomerulonephritis (APSGN) have an excellent prognosis, which contrasts with the poor long-term outcome of sporadic cases. Therapy is largely supportive. Rarely, the disease shows long-term complications, worsening to chronic kidney disease requiring long-term interventional measures. To compare the effectiveness of different therapeutic strategies for the prevention and treatment of APSGN in childhood, the authors reviewed randomized controlled trials on the prevention and treatment of APSGN in children. Nine studies fit the inclusion criteria. Primary outcomes were the development of APSGN, the effectiveness of medication for controlling hypertension, and the development of chronic renal failure in patients with crescentic glomerulonephritis. No advantages of antimicrobials (cefuroxim, ceftibuten, and others) given for 5 days were found over penicillin V given for 10 days (4 trials). Nifedipine showed advantages in controlled acute hypertension (1 trial). ACE inhibitors (captopril and enalapril) had better control of blood pressure and echocardiographic changes than other antihypertensive drugs/diuretics (2 trials). The use of combined immunosuppressants for crescentic poststreptococcal glomerulonephritis showed no advantages over supportive therapy alone (1 study). The studies were of small number and with limitations that seriously weaken the results.

PMID 20357732  Med Sci Monit. 2010 Apr;16(4):RA79-84.
著者: Bernardo Rodriguez-Iturbe, James M Musser
雑誌名: J Am Soc Nephrol. 2008 Oct;19(10):1855-64. doi: 10.1681/ASN.2008010092. Epub 2008 Jul 30.
Abstract/Text Poststreptococcal glomerulonephritis is one of the oldest recognized renal diseases. In the past three decades, significant changes have occurred in its epidemiology, in new insight gained in the nephritogenic characteristics of streptococcal antigens, and in the natural history of the disease. The disease is now rare in industrialized nations, but in the underprivileged world, the burden of poststreptococcal glomerulonephritis ranges between 9.5 and 28.5 new cases per 100,000 individuals per year. Prophylactic antibiotic treatment is advisable in epidemic conditions and to household contacts of index cases in communities where the prevalence of the disease is high. The long-term prognosis is variable; in general, prognosis is excellent in children but significantly worse when it occurs in elderly individuals and in populations that present other risk factors of chronic kidney disease. Contemporary large-scale research strategies such as genome-wide sequencing may uncover new information about pathogenic factors contributing to disease.

PMID 18667731  J Am Soc Nephrol. 2008 Oct;19(10):1855-64. doi: 10.1681・・・
著者: T Kasahara, H Hayakawa, S Okubo, T Okugawa, N Kabuki, S Tomizawa, M Uchiyama
雑誌名: Pediatr Int. 2001 Aug;43(4):364-7.
Abstract/Text BACKGROUND: Recently, the prognosis of acute poststreptococcal glomerulonephritis (APSGN) has been reported as improved, compared with the results of previous studies. In an attempt to clarify this, we analyzed the clinical course of patients with APSGN.
METHODS: A total of 220 children with acute nephritic syndrome were treated in the affiliated hospitals of our department, between January 1988 and December 1997. Among them, 138 children who were diagnosed with APSGN according to the presence of hematuria, transient hypocomplementemia and evidence of group A beta-hemolytic streptococcal infection, were studied.
RESULTS: Serum creatinine and blood urea nitrogen levels at onset were 0.5 +/- 0.2 mg/dL and 20 +/-12 mg/dL, respectively. There were no patients with renal dysfunction (serum creatinine level > or = 1.5 mg/dL), but one patient with nephrotic syndrome. Blood pressure was well controlled in all patients and there were no patients with persistent hypertension. Serum complement levels were normalized within 12 weeks (100%), hematuria disappeared within 4 years (100%) and proteinuria disappeared within 3 years (100%) from the onset.
CONCLUSIONS: These data indicate that the prognosis of APSGN during childhood is excellent, when adequately diagnosed and treated.

PMID 11472580  Pediatr Int. 2001 Aug;43(4):364-7.
著者: J W Lien, T H Mathew, R Meadows
雑誌名: Q J Med. 1979 Jan;48(189):99-111.
Abstract/Text The long-term outcome after acute post-streptococcal glomerulonephritis was studied in 57 patients (52 aged 16 or over) followed for a period of one to 14 years (mean seven years). All patients presented with hypertension, haematuria and proteinuria. The antistreptolysin-0 titre was raised or the serum complement was low in all cases at the initial episode. All patients had histological evidence of a diffuse proliferative and exudative glomerulonephritis at onset. Follow-up renal biopsy was performed in 33 patients; in 18 patients this was carried out five years or more after the initial illness. Five patients died beyond two years, only two having had abnormal renal function at the time or death. Four patients were found to be mildly hypertensive without other clinical abnormalities. Eleven patients had proteinuria, haematuria or abnormal renal function; in three of these repeat renal biopsy was normal, incomplete resolution was reported in five, obsolescent glomeruli in one, and two others were not biopsied. No patient who had normal renal function at the time of follow-up had abnormal renal histology on biopsy. Obsolescent glomeruli were present in two other biopsies in association with evidence of incomplete resolution. It was concluded that the majority of patients with acute PSGN have a good prognosis. Histological resolution of the renal lesion may not occur for nine years.

PMID 482595  Q J Med. 1979 Jan;48(189):99-111.
著者: Ricardo Sesso, Sergio Wyton L Pinto
雑誌名: Nephrol Dial Transplant. 2005 Sep;20(9):1808-12. doi: 10.1093/ndt/gfh904. Epub 2005 May 26.
Abstract/Text BACKGROUND: In 1998 there was a large outbreak of acute glomerulonephritis in Nova Serrana, Brazil, caused by group C Streptococcus zooepidemicus. This study describes the follow-up of these patients, after a mean time of 5.4 years of the acute episode.
METHODS: Of 135 cases identified in 1998, 56 were re-examined in a prospective study and had measurements of blood pressure, creatinine clearance (estimated by the Cockcroft and Gault formula), microalbuminuria (radioimmunoassay), urine sediment analysis and a protein dipstick test.
RESULTS: Of the original group of 135 subjects, 3 died in the acute phase and 5 (3.7%) required chronic dialysis. Of the 56 cases re-evaluated, 54 (96%) were adults (mean+/-SD age, 43+/-17 years) and 36 (64%) females. At the follow-up examination, we found arterial hypertension in 30% (n = 17/56) of the subjects, reduced creatinine clearance (<80 ml/min) in 49% (n = 26/53) and increased microalbuminuria (>20 microg/min) in 22% (n = 11/51). Compared to the evaluation carried out 3 years before, the number of cases with creatinine clearance lower than 80 ml/min increased from 20 to 26 (of 53 cases). Increased microalbuminuria and/or reduced creatinine clearance were detected in 57% (n = 32/56) of the subjects. Patients with reduced creatinine clearance were older than those without reduced renal function (54+/-15 vs 34+/-12 years, P<0.001).
CONCLUSIONS: After a mean time of 5.4 years, a relatively high proportion of patients with epidemic poststreptococcal glomerulonephritis due to S.zooepidemicus present hypertension, reduced renal function and increased microalbuminuria.

PMID 15919694  Nephrol Dial Transplant. 2005 Sep;20(9):1808-12. doi: 1・・・
著者: S W Pinto, R Sesso, E Vasconcelos, Y J Watanabe, A M Pansute
雑誌名: Am J Kidney Dis. 2001 Aug;38(2):249-55. doi: 10.1053/ajkd.2001.26083.
Abstract/Text In 1998 there was a large outbreak of acute glomerulonephritis (GN) in Nova Serrana, Brazil, caused by group C Streptococcus zooepidemicus and linked to the consumption of contaminated cheese produced with unpasteurized milk. This study describes the follow-up of these patients after a mean of 2 years following the acute episode. Of 134 patients identified in 1998, 69 patients were reexamined and underwent measurements of blood pressure, 24-hour creatinine clearance, microalbuminuria (radioimmunoassay), and urine sediment analysis. Of the original group of 134 patients, 3 patients died in the acute phase and 5 patients (3.7%) required chronic dialysis. Of 69 patients reevaluated, 65 patients (94%) were adults (mean age, 39 +/- 2 [SE] years) and 47 patients (68%) were women. At the follow-up examination, we found arterial hypertension in 42% of subjects (27 of 64 subjects), serum creatinine levels greater than 1.2 mg/dL in 12% (10 of 68 subjects), reduced creatinine clearance (<80 mL/min/1.73 m(2)) in 30% (20 of 67 subjects, 2 of them on chronic dialysis therapy), and increased microalbuminuria (>20 microg/min) in 34% (22 of 65 subjects). Increased microalbuminuria and/or reduced creatinine clearance were detected in 48% of the subjects (31 of 65 subjects). Patients with microalbuminuria had greater diastolic blood pressure than those without microalbuminuria (mean, 98 +/- 4 versus 88 +/- 2 mm Hg; P = 0.02). In conclusion, after a mean of 2 years, patients with epidemic poststreptococcal GN caused by S zooepidemicus present a high rate of hypertension and frequent abnormalities of renal function, with some having reached end-stage renal disease. Longer follow-up will be important to define the prognosis of these patients.

PMID 11479149  Am J Kidney Dis. 2001 Aug;38(2):249-55. doi: 10.1053/aj・・・
著者: Wendy E Hoy, Andrew V White, Alison Dowling, Suresh K Sharma, Hilary Bloomfield, Bernard T Tipiloura, Cheryl E Swanson, John D Mathews, David A McCredie
雑誌名: Kidney Int. 2012 May;81(10):1026-32. doi: 10.1038/ki.2011.478. Epub 2012 Feb 1.
Abstract/Text Although unusual in western countries and in Australia in general, post-streptococcal glomerulonephritis (PSGN) is still common in Australian Aboriginal children living in remote communities. Here, we evaluated whether episodes of acute PSGN increased the risk for chronic kidney disease in later life in 1519 residents of a remote Aboriginal community (85% of those age eligible), with high rates of renal and cardiovascular disease, who participated in a health screen over a 3-year period. Of these, 200 had had at least one episode of PSGN, with 27 having had multiple episodes, usually in childhood. High levels of albuminuria (albumin/creatinine ratio) with increasing age were confirmed. All PSGN episodes were associated with group A streptococcal skin infections, often related to scabies. In both genders, aged 10-39 years at screening, about one in five had such a history. Among them, PSGN (5 years or more earlier) was significantly associated with higher levels of albuminuria than those without. In women, aged 30-39 years, a history of PSGN was associated with a significantly higher frequency of estimated glomerular filtration rates <60 ml/min. The adjusted odds ratios for an albumin/creatinine ratio over 34 g/mol (overt albuminuria) in males and females with a history of PSGN were 4.6 and 3.1, respectively, compared with those without a history. Thus, PSGN contributes to the very serious burden of chronic kidney disease in this community. Rigorous strategies to prevent scabies and Group A streptococcal infections will reduce this burden.

PMID 22297679  Kidney Int. 2012 May;81(10):1026-32. doi: 10.1038/ki.20・・・
著者: José Herrera, Bernardo Rodríguez-Iturbe
雑誌名: Kidney Int Suppl. 2003 Feb;(83):S22-6. doi: 10.1046/j.1523-1755.63.s83.6.x.
Abstract/Text BACKGROUND: Goajiro Indians are a semi-nomad tribe that live on the Goajiro peninsula, in the northwestern part of Venezuela. We investigated the incidence of end-stage renal disease (ESRD) and post-streptococcal glomerulonephritis (PSGN) among Goajiros and to determine if it was increased and whether congenital endowment of low number of nephrons (as indicated by low birth weight) was a contributing factor in their predisposition to chronic renal failure (CRF).
METHODS: The incidence of ESRD and the attack rate of poststreptococcal glomerulonephritis (PSGN) among Goajiros during the period December 1991 through December 1998 were evaluated from the records of the University Hospital, in Maracaibo, which is the referral center for Goajiro Indians. Demographic characteristics and birth weight were obtained from the records of the Regional Public Health Service. Subclinical reduction in renal functioning mass was investigated in 11 healthy Goajiros with a standardized tubular stress test that determines the increment in tubular secretion of creatinine (TSCr) resulting from the intravenous administration of a bolus of creatinine.
RESULTS: The incidence of ESRD among Goajiros was 220 patients per million inhabitants per year, 1.7 times higher than the incidence for the country. The attack rate of post-streptococcal glomerulonephritis is nearly double among Goajiro Indians (2.9 +/- 1.3 cases/100,000 inhabitants/year) than in the general population in the neighboring Maracaibo city (1.5 +/- 0.3, P < 0.02). Low weight birth was common among Goajiros; as many as 23% of newborns weigh less than 1000 g. The stimulated TSCr in healthy Goajiros was 30% lower than in controls (P < 0.001).
CONCLUSIONS: Goajiro Indians have a high incidence of ESRD. A high attack rate of PSGN and low nephron endowment in combination may be responsible, at least in part, for the increased risk of ESRD in this population.

PMID 12864870  Kidney Int Suppl. 2003 Feb;(83):S22-6. doi: 10.1046/j.1・・・

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