Antibody to streptococcal zymogen in the serum of patients with acute glomerulonephritis: a multicentric study.

BACKGROUND: Cationic streptococcal proteinase (erythrotoxin B) and its precursor, zymogen, are putative nephritogenic antigens. The present study was designed to test whether serum titers to these antigens were good markers of streptococcal infection associated with glomerulonephritis. METHODS: We studied 153 patients (male/female = 104/49, age range, 2 to 23 years old) with acute poststreptococcal glomerulonephritis (APSGN) from three countries (Venezuela, Chile and Argentina). The site of the initial infection was the skin in 84 patients, the throat in 55 patients and was unknown in 14 patients. In addition, we studied 23 patients (1 to 24 years old) with streptococcal infection not associated with glomerulonephritis (14 patients with impetigo and 9 patients with pharyngitis). As control group, 93 healthy individuals (54 males, 2 to 19 years old) were studied. Anti-zymogen and anti-proteinase titers were determined in a single laboratory by ELISA, and the intra- and interassay coefficients of variation were 5.3% and 8.5%, respectively. ASO titers and anti-DNAse B titers were also done. RESULTS: Anti-zymogen titers of 1:800 to 1:3200 had likelihood ratios (sensitivity/1-specificity) for detection of streptococcal infection in APSGN patients ranging from 2.00 to 44.2 in Argentina, Chile and Venezuela. Anti-zymogen titers decreased one to two months after APSGN and they were 1 to 3 log2 dilutions higher that anti-proteinase titers. Receiver operating characteristic (ROC) curves showed that anti-zymogen titers were consistently superior to anti-streptolysin O and anti-DNAse B titers as markers for streptococcal infection in APSGN. CONCLUSIONS: These results suggest that increased anti-zymogen antibody titers are the best available marker for streptococcal infection associated with acute glomerulonephritis.

Immunohistochemical localization of IL-8 and TGF-beta in streptococcal glomerulonephritis.

Acute poststreptococcal glomerulonephritis (APSGN) is characterized by diffuse glomerular hypercellularity, primarily as a result of accumulation of neutrophils (exudative glomerulonephritis), increase in intrinsic glomerular cells, and transient pathological mesangial matrix expansion. Cytokines and growth factors are supposed to play an important role as mediators of inflammation and as progression factors in various renal disorders. Interleukin-8 is a recently described cytokine, defined as a selective activator and chemoattractant of polymorphonuclear leukocytes (PMNL) and transforming growth factor (TGF)-beta plays a central role in the accumulation of pathological extracellular matrix in glomerulonephritis. This study analyzed the biopsies of ten patients with APSGN, using immunohistochemistry (avidin-biotin complex/horseradish peroxidase method) using monoclonal antibodies anti-IL-8, anti-TGF-beta 1, beta 2, beta 3. Controls consisted of non-immune mouse serum, or anti-TGF-beta preabsorbed with human recombinant TGF-beta. Compared with normal renal tissue, and minimal change disease, an increased glomerular IL-8 and TGF-beta staining was observed in all of the biopsies. Furthermore, in one patient, we observed a weak deposit of TGF-beta in tubulointerstitium. Immunoreactive IL-8 and TGF-beta in glomeruli was correlated with light microscopic and clinical features. There was a significant association (P < 0.05), between IL-8 glomerular immunoreactivity and neutrophil infiltration and between TGF-beta glomerular staining and mesangial matrix expansion. Otherwise, there was no correlation with the mesangial cellularity. It was concluded that increased protein expression of IL-8 and TGF-beta are observed in APSGN and may play a role in the acute glomerular inflammation.

Decreased platelet counts and decreased platelet serotonin in poststreptococcal nephritis.

Mean platelet survival time in patients with acute poststreptococcal glomerulonephritis (APSGN) is reduced to 50-60% of the control values, and glomerular deposits of platelet factor 4 are found in these patients. In order to investigate further systemic platelet changes of pathogenic, clinical or prognostic significance, we measured the platelet serotonin (5-HT) content and the blood platelet counts during the 1st week of the disease in 27 patients with APSGN. Platelet 5-HT was significantly reduced in patients with APSGN as compared with patients with impetigo without glomerular involvement (785 +/- 54 vs. 1,329 +/- 94 ng 5-HT/10(9) platelets; p < 0.001). Similarly, the mean blood platelet count was reduced to 247 +/- 16 x 10(3) as compared with 303 +/- 14 x 10(3) in the controls (p < 0.05). Thirteen (48%) of these patients had individual values of platelet 5-HT lower than the 95% confidence interval calculated in the control group. No significant correlation was observed between the concentration of 5-HT and either the severity of the disease judged by the amount of urinary protein excretion and the serum creatinine value or the presence of circulating immune complexes. Significant correction of the platelet 5-HT content (to 1,180 +/- 111 ng/10(9) platelets; p < 0.01) and of the platelet counts (to 309 +/- 21 x 10(3); p < 0.01) were observed in the longitudinal study at least 2 weeks later. Platelet activation, with secretion of granular content and increased consumption, may explain these findings. Additionally, the reduced mean age of the circulating platelets could contribute to their decreased 5-HT levels.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hemolytic uremic syndrome in childhood: study of several factors potentially related with its genesis]. / Síndrome hemolítico urémico en el niño: estudio de algunos factores potencialmente relacionados con su génesis.

We measured circulating immune complexes, tumor necrosis factor and antineutrophil cytoplasmatic antibodies in sera coming from 25 patients during the acute reactant phase of the classical form of hemolytic uremic syndrome, aiming to elucidate a potential participation of these parameters in the pathogenesis of the disease. Circulating immune complexes were elevated in the 18 patients in whom they were measured. Tumor necrosis factor was not elevated and antineutrophil cytoplasmatic antibodies were not detected. It is concluded that these results rule out the participation of antineutrophil cytoplasmatic antibodies in the pathogenesis of the disease and that the role of circulating immune complexes, although elevated, remains undefined.

Detection of platelet-activating factor in plasma of patients with streptococcal nephritis.

The purpose of this study was to evaluate whether platelet-activating factor (PAF) is released in the plasma of patients with acute poststreptococcal glomerulonephritis, because previous studies have shown an involvement of platelets in the active phase of this disease. The results of this study indicate that PAF bioactive material is released in significant amounts in the plasma of 49 out of 50 patients with acute poststreptococcal glomerulonephritis. The observed release of PAF was not a direct consequence of the bacterial infection, because it was minimal or absent in patients with streptococcal infection without glomerular involvement. PAF bioactive material extracted and purified from the plasma of patients was shown to be chemically and biologically identical to the synthetic C-16 PAF (1-O-hexadecyl-2-acetyl-sn-glyceryl 3-phosphorylcholine).

Antineutrophil-cytoplasmic-autoantibodies in poststreptococcal nephritis.

Sera from 210 patients with APSGN, were tested for the presence of ANCA (IgG-isotype). Indirect immunofluorescence (IF) on ethanol fixed human PMNs was used, and for those positive sera, ELISA kits for PR3 (Proteinase 3) and MPO (Myeloperoxidase) was performed. ANCA were detected in 9% (18 out of 210 cases) in a predominantly diffuse cytoplasmic staining pattern in 14 cases (77%), and in a perinuclear pattern in the remaining 4 cases (22%). Anti-MPO was found in 4 cases (C-ANCA 3; P-ANCA 1) and anti-PR3 was always negative. The presence of ANCA was significantly associated with a more severe glomerular disease as assessed by the serum creatinine value and the crescents formation. Longitudinal studies performed in 11 cases have shown that raised levels of these autoantibodies may persist for at least six months, without relationship with disease activity. Further studies are required to dilucidate the specificity of these autoantibodies, and if its presence is either an epiphenomenon of the heterogeneous humoral immune response in streptococcal infection, or they play some pathogenic role in APSGN.

Glomerular localization of platelet factor 4 in streptococcal nephritis.

Since platelet factor 4 (PF4), a cationic (pI 7.6) platelet secretory protein, binds avidly to glomerular polyanions both in vitro and in vivo, and is implicated in neutrophil chemotaxis, we studied by indirect immunofluorescence microscopy the presence of PF4 deposits in glomeruli of patients with poststreptococcal nephritis (APSGN). Goat antihuman PF4 serum was used as primary antibody and fluorescein-conjugated IgG fraction of rabbit antigoat IgG as second antibody. Controls consisted of nonimmune goat serum or anti-PF4 serum preabsorbed with human PF4, as primary antibodies. Glomerular deposits of PF4 were demonstrated in renal tissues obtained by biopsy in 14 of 20 patients studied; the deposits were particularly intense in 9 patients. PF4 was bound to the mesangium and to the capillary walls. There was a significant positive correlation between intraglomerular deposits of PF4 and the levels of proteinuria (p = 0.024). These findings provide further evidence for a role of platelets in the pathogenesis of APSGN and suggest that PF4 may contribute to alter the glomerular permeability in this disease.

Age influence on mononuclear phagocyte system Fc-receptor function in poststreptococcal nephritis.

The Fc-receptor function of the mononuclear phagocyte system (MPS) was examined in 41 children and adult patients, by measuring the clearance of IgG-sensitized, 51Cr-labeled erythrocytes. The Fc-receptor-mediated clearance observed in patients (mean +/- SE) was not significantly different as compared to the control group of similar age distribution. However, the immune clearance time was significantly age-correlated in both groups (acute poststreptococcal glomerulonephritis, APSGN, r = 0.39, p less than 0.05; control r = 0.63, p less than 0.01). The magnitude of the Fc-specific immune clearance and the serum creatinine were also significantly correlated (r = 0.59; p less than 0.01). Circulating immune complexes (as measured by the C1q and conglutinin ELISA) did not correlate with immune clearance, which remained stable in longitudinal studies. Age-related changes in MPS Fc-receptor function could explain, at least in part, prognostic differences between children and adult patients with APSGN.

Decrease in mean platelet survival time in acute poststreptococcal glomerulonephritis (APSGN).

In an attempt to study further the possible participation of platelets in the pathogenesis of acute poststreptococcal glomerulonephritis (APSGN), we studied the platelet survival time, as an index of platelet activation, in 22 patients with APSGN. Mean platelet survival time was computed from the disappearance of radioactivity from blood, sampled serially after injection of autologous 51Cr-labelled platelets. C1q solid phase ELISA and conglutinin (K) solid phase ELISA were used to measure the serum levels of immune complexes. The platelet survival time in APSGN patients was 113 +/- 10 h vs 197 +/- 10 h in the control group (p less than 0.001); 68% of the patients had a shortened platelet survival, lower than 95% confidence limit. There was a significant increase in the platelet survival in the six patients that were studied after recovery from acute nephritic syndrome. There was no significant association between the mean platelet times survival and CICs (circulating immune complexes). Similarly, no significant correlation was found between the mean platelet lifespan and the severity of the glomerular disease, as assessed by the serum creatinine level and the proteinuria. These results support evidence of platelet activation and consumption in APSGN and we suggest that this activation occurs in the glomeruli capillary wall, due to platelet-vascular wall interaction.

[Influence of gestational age and postnatal kidney maturation on the kinetics of gentamicin]. / Influencia de la edad gestacional y maduración renal postnatal en la cinética de gentamicina.

The current schedule for gentamicin administration to newborn infants, in doses of 2.5 mg/kg every twelve hours during the first week of life was evaluated in pre-term newborns under 35 weeks of gestational age (GA). Pharmacokinetic studies in steady state conditions were performed at the third and seventh days of therapy (periods A and B respectively) in nine pre-term (GA 30 to 34 weeks) and ten full-term newborns. Minimal gentamicin blood concentrations at period A were 1.96 +/- 0.32 micrograms/ml in term newborns and 2.51 +/- 0.48 micrograms/ml in pre-term infants (p less than 0.005) and, at period B, 1.49 +/- 0.37 micrograms/ml and 2.33 +/- 0.34 respectively (p less than 0.001). Gentamicin excretion showed good correlations with gestational age (r: 0.654; p less than 0.005) and creatinine clearance (r: 0.628; p less than 0.005).

Presence of circulating immune complexes in the classic form of hemolytic uremic syndrome: a constant finding.

In an attempt to further study the possible contribution of circulating immune complexes (CIC) in the pathogenesis of the classic form of hemolytic uremic syndrome, 9 patients were studied during the acute phase of the diseases. C1q solid-phase ELISA and conglutinin solid-phase ELISA, were used to measure the levels of immune complexes. All 9 were positive in one or both assays. No correlation was found between the levels of CIC and the clinical severity of the disease. The constant finding of positive CIC in these patients might represent an epiphenomenon, point out the postinfectious nature of this disease but also suggest a possible pathogenic role.