Outcomes and Predictors of Acute Post‐Streptococcal Glomerulonephritis in Hospitalized Children in Northwest Ethiopia: A Multicenter Retrospective Cohort Study

ABSTRACT

Background

Acute post‐streptococcal glomerulonephritis (APSGN) is one of the most critical health conditions. It remains an important cause of acute kidney injury, hospitalization, and long‐term complications for children. Thus, this study aimed to assess the treatment outcome of APSGN and its predictors among pediatric patients at Comprehensive Specialized Hospitals in Northwest Ethiopia.

Methods

An institutional retrospective cohort study was conducted on pediatric patients, reviewing medical records from admission to treatment outcome between September 01, 2018, and August 30, 2024. The collected data were entered using the Epi Data software (version 4.6.0.0) and exported to SPSS version 25.0. Adjusted odds ratio (AOR) with a corresponding 95% confidence interval (CI) and p value < 0.05 were used to identify significant factors affecting the treatment outcome.

Results

Most patients with acute post‐streptococcal glomerulonephritis demonstrated positive treatment outcomes, with 70.2% recovering completely. The majority of patients arrived at the hospital more than 2 weeks after infection, with 70.8% hospitalized for over 2 weeks. Children aged 5–9 years faced significantly higher odds of negative outcomes (AOR = 2.61, 95% CI: 1.34–5.10, p = 0.006), while those aged 10–15 years did not show a significant association. Acute kidney injury (AOR = 1.70, 95% CI: 1.08–2.93, p = 0.032) and an infection duration over 2 weeks (AOR = 2.14, 95% CI: 1.06–4.32, p = 0.024) were linked to worse outcomes. Additionally, an evident source of infection was associated with negative outcomes (AOR = 2.13, 95% CI: 1.25–5.13).

Conclusion

The majority of patients with acute post‐streptococcal glomerulonephritis recovered completely. Significant predictors of negative treatment outcomes included age, the evident source of infection, the duration of infection at admission, and the presence of acute kidney infection at admission. There should be a focus on treatment outcomes through thorough evaluation, follow‐up, and monitoring.

1. Introduction

Acute post‐streptococcal glomerulonephritis (APSGN) is an inflammatory response to infection in the renal glomeruli that is accompanied by urinary findings of nephritis; the patient may develop edema, hematuria, and hypertension after acquiring certain serotypes of this infection of the skin or throat. APSGN is caused by an infection with group A β‐hemolytic streptococci, which results from disease of the throat or the skin by nephrogenic streptococci, and upper airway infections, such as pharyngitis or tonsillitis [1, 2, 3].

The magnitude of APSGN worldwide is approximately 472,000 cases per year. New strains spread very quickly in communities with high levels of scabies, skin sores, and overcrowded living conditions [4]. It is the most common form of acute glomerulonephritis (AGN), particularly in children. Viral, bacterial, and protozoan organisms can cause infections, with subsequent acute post‐infectious glomerulonephritis [5]. APSGN in childhood is a risk factor for CKD, even after the complete remission of the infection, according to long‐term epidemiological analysis [6]. APSGN became notifiable in the Northern Territory of Australia [7]. According to a study in Mekele city; age, duration of infection, source of infection, and length of stay in the hospital were statistically significant factors associated with negative treatment outcomes of APSGN infection in children [8]. Because of easier and earlier access to medical treatment of streptococcal infections and the widespread use of fluorination of water since virulence factors in streptococcus pyrogens are reduced with fluoride exposure, APSGN is rare in developed countries, but high in low‐income countries [9].

APSGN has a good prognosis, with full recovery of renal function in 90% of cases [10]. In pediatric nephrology, APSGN is one of the most critical health conditions. It remains an important cause of acute kidney injury and hospitalization for children; although the final treatment outcome is excellent in most cases [11]. It is most common in children aged 5–12 years and uncommon before the age of 3 years. The typical patient develops an acute nephritic syndrome 3–6 weeks after a streptococcal pyoderma or 1–2 weeks after an antecedent streptococcal pharyngitis. Chronic kidney disease occurs in less than 1% of children and a higher percentage of adults [12, 13].

Recent advances in nephrology have expanded the understanding of post‐streptococcal glomerulonephritis (PSGN) into the broader category of infection‐related glomerulonephritis (IRGN) [14]. This includes immune‐mediated glomerular injuries resulting from infections, whether occurring after (post‐infectious GN) or concurrently with (syn‐infectious GN) the infection. For instance, staphylococcal infection–associated glomerulonephritis often occurs with active infection, unlike classical PSGN, which follows a latent period post‐streptococcal infections [15]. The timing of glomerular injury in relation to the infection, along with variations in pathogens and host responses, affects clinical presentation, histopathology, and prognosis, underscoring the need to differentiate these patterns in clinical and research contexts [16, 17].

APSGN is typically followed by clinical recovery over several days to weeks. However, some studies have suggested that this illness is followed by an increase in chronic kidney disease [18]. Acute kidney injury, cardiac failure, sepsis, or hypertensive encephalopathy can all occur in pediatrics with APSGN infection, and these outcomes are worse in adults than pediatric population [19, 20]. The rarity of APSGN and the common use of antibiotics for Group A Streptococcus (GAS) infections limit comprehensive studies on the protective effects of antibiotics. Early antibiotic treatment can prevent APSGN, while prophylactic antibiotics help contain the spread of nephritis‐related streptococcal infections among at‐risk patients. Individuals with APSGN should be treated as if they have an active streptococcal infection, as positive cultures may be found even when upper respiratory or skin infections are not clinically apparent [21, 22].

APSGN infection has no specific treatment. Treatment is focused on relieving symptoms. Antibiotics should be used to eradicate streptococcal bacteria in the body, and antihypertensive drugs and diuretics may be needed to control edema and hypertension like angiotensin‐converting enzyme inhibitors (ACEIs), diuretics, but ACEIs carry the risk of hyperkalemia and transient impairment of kidney function [23]. APSGN represents a risk factor for the subsequent development of CKD if associated with diabetes and obesity [19, 20]. Similarly, APSGN is a common disease in Ethiopian children [8, 24].

APSGN is a common cause of acute kidney injury in children, particularly in developing countries [25], and it remains a significant public health challenge, especially in children, and thus understanding the outcomes and predictors for APSGN is critical for improving patient care and informing clinical guidelines [6, 26].

This study focused on the pediatric population that is disproportionately affected by APSGN infection. Studies conducted in Ethiopia about APSGN are limited, particularly in Northwest Ethiopia. Thus, this study was focused on the assessment of the outcomes of APSGN and its predictors among pediatric patients who had been admitted to Comprehensive Specialized Hospitals in Northwest Ethiopia. Health policymakers and administrators can use the findings of this study to develop effective problem‐focused strategies to minimize morbidity and mortality related to APSGN. The result of this study will also help in alerting clinical pharmacists to expand their professional role in improving the APSGN treatment outcome.

2. Methods and Materials

2.1. Study Design, Setting, and Study Period

The study was conducted at three comprehensive specialized hospitals in Northwest Ethiopia, selected among five comprehensive specialized hospitals in the northwest Ethiopia by lottery method. Debre Markos, Debre Tabor, and Felege Hiwot comprehensive specialized hospitals were the study settings. Debre Tabor Comprehensive Specialized Hospital, South Gondar zone, Amhara region, Ethiopia, which is located 667 km from Addis Ababa, and 103 km from Bahir Dar City. This hospital has 120 beds and 6 admission wards, namely the pediatric ward, medical ward, orthopedic ward, psychiatric ward, gynecology ward, and surgical ward. At the pediatric ward, there are 43 admission beds. Debre Tabor City is located in the South Gondar administration Zone of the Amhara Regional State Northwest Ethiopia; its climatic condition is “Dega”. Felege Hiwot Comprehensive Specialized Hospital is located in Bahir Dar City, the capital of the region, which is 565 km from Addis Ababa, and Debre Markos CSH is located 300 km from Addis Ababa. Each hospital serves about 5 million people.

A retrospective cohort study was conducted to determine the treatment outcome of acute post‐streptococcal glomerulonephritis and its associated factors among pediatric patients who had been admitted to Debre Tabor Comprehensive Specialized Hospital from September 1, 2018, to August 30, 2024. Pediatric patients' medical records were followed up longitudinally from admission to treatment outcome. The study was conducted (data collection period) from September 18 to October 30, 2024.

2.2. Study Participants and Eligibility Criteria

All pediatric patients' medical records with confirmed diagnoses of APSGN at Debre Tabor Comprehensive Specialized Hospital were the source population, and the study population was all selected of pediatric patients' medical records with APSGN from September 1, 2018, to August 30, 2024. All pediatrics' medical records with a diagnosis of APSGN and complete medical records were included in the present study and incomplete medical records were excluded.

2.3. Variables of the Study

The outcome variable was treatment outcome (positive and negative treatment outcomes), and independent variables were socio‐demographic and clinical characteristics such as gender, age, residence, reasons for presentation, duration of infection, source of infection, nutritional status, clinical conditions, and complications.

2.4. Sample Size Determination and Sampling Technique

The sample size is computed using the general formula for a single population proportion. It is calculated by using a 5% margin of error, 95% confidence interval (CI), and the prevalence (P) of 90 (26.9%) who had not recovered completely (negative outcome) [8]. The sample size is calculated using the single population proportion formula as follows.

$${n=z}_{a/2}^{2}p(1‐p){/d}^2$$

$$n={\left(1.96\right)}^{2}0.269(1‐0.269)/{\left(0.05\right)}^2$$

$$n=302$$

where; n = required sample size

p = estimated prevalence

z = z‐score at 95%CI

d = margin error of 5%

Therefore, with consideration of 10% expected incomplete patient medical records, the final sample size was 332 pediatric patient medical records. Completed data from patients' medical records were used. Pediatric patient medical records were selected using a simple random sampling technique based on the sampling frame prepared from the medical records of pediatric patients who had been admitted from September 1, 2018 to August 30, 2024, at Comprehensive Specialized Hospitals. The sampling procedure for participants admitted to the pediatric ward with acute post‐streptococcal glomerulonephritis is illustrated below (Figure 1). The data were recorded in the structured checklist developed from different literature [1, 6, 7, 8, 12, 21, 23, 24].

Figure 1.

Sampling procedure of the study participants admitted to the pediatric ward with acute post‐streptococcal glomerulonephritis (n = 332).

2.5. Operational Definitions

APSGN: pediatric patients with APSGN admitted with abrupt onset of edema, hematuria, hypertension, oliguria, and impaired kidney function following streptococcal group A β‐hemolytic streptococcal throat and skin infection [27].

Diagnostic criteria of APSGN: APSGN is diagnosed as follows [20]:‐

• I.Clinical evidence: at least two of the following: (1) Facial edema and/or peripheral edema, (2) hypertension, or (3) ≥ moderate hematuria on dipstick (≥ 2+ red blood cells)
• II.Laboratory evidence:

• 1.Hematuria on microscopy (RBC > 10/μL) (if microscopy is not available, “moderate” hematuria on dipstick fulfils this criterion),
• 2.Evidence of recent streptococcal infection (positive Group A Streptococcal culture from skin or throat, or elevated ASO titer or Anti‐DNase B), and
• 3.Reduced C3 complement level (hypocomplementemia). Hemolytic complement plasma C3 level was defined as normal if its range is between 0.6 and 1.5 g/L.

• III.The normal range of anti‐streptococcal O titer (ASO titer) was considered as 0–200 IU/mL.

Pediatric patient: a child less than 15 years old [24].

Hematuria: hematuria is the presence of at least five red blood cells (RBCs) per microliter of urine in the microscope, or a 1+ positive urinary dipstick reading [24].

Proteinuria: this is when ≥ 1+ to 3+ urinary dipstick readings, or 4–40 mg/m²/h in 24‐h urine measurement [24].

Creatinine level: creatinine level was defined as normal if an estimated glomerular filtration rate (GFR) > 90 mL/min/1.73m², and abnormal if GFR is below 90 mL/min/1.73m² [28].

Hemoglobin level: hemoglobin level was defined as normal if patients have a hemoglobin level > 10 g/dL [12].

Outcome definition:

• a.Positive treatment outcome: characterized by patient recovery and discharge without clinical complications.
• b.Negative treatment outcome: Involve occurrences such as death or the development of severe complications during hospitalization, including severe hypertension, renal impairment, or other complications related to Acute Post‐Streptococcal Glomerulonephritis (APSGN) at the time of discharge.

Hypertension: Hypertension is defined as blood pressure in which systolic and or diastolic blood pressure is ≥ 95th percentile on ≥ 3 occasions determined for sex, age, and height [29].

2.6. Data Collection Procedures and Techniques

The data were collected through observation of the patient's medical records retrospectively (from admission until treatment outcome) and randomly sampled among medical records of pediatric patients at Comprehensive Specialized Hospitals from September 1, 2018 to August 30, 2024. After having 1 day of training about the objectives of the study and ethical aspects, two clinical pharmacists collected the data. The data obtained from observation were recorded by preparing the checklist. The collected data were checked for completeness and consistency before data entry and analysis.

2.7. Data Quality Control and Data Processing

Data was collected from the medical records of submitted patients and checked for completeness, accuracy, clarity, and consistency before being entered into Microsoft Excel. When any ambiguity or incompleteness is encountered, the problem is assessed and corrected before proceeding to the next step. The collected data were compiled, cleared, coded, and checked for completeness and accuracy, and entered using the Epi Data software (version 4.6.0.0) and exported to SPSS version 25.0. Explanatory variables and treatment outcome profiles were subjected to descriptive statistical analysis, which was used to determine the frequency and/or percentages.

2.8. Statistical Analysis

To analyze the factors associated with the treatment outcome, both χ ² and binary logistic regression analysis were carried out based on the fitness test. For the bivariate and multivariable analysis, treatment outcome was dichotomized into positive treatment outcome and negative treatment outcome. A p value of less than 0.05 was considered statistically significant. Multivariable logistic regression identified factors associated with negative treatment outcomes, such as age, delayed presentation, hypertension severity, and acute kidney injury at admission. The model showed 99 negative outcomes, with an events‐per‐variable (EPV) the recommended threshold. Variance inflation factors indicated no significant multicollinearity, and the model's fit was evaluated using the Hosmer–Lemeshow goodness‐of‐fit test.

2.9. Ethics Approval

Ethical approval for this study was obtained from the ethical review committee of the Debre Tabor University, College of Health Sciences; research & community service coordination office with the reference number DTU/CHS/1634/2024, and a permission letter was obtained from Debre Tabor Comprehensive Specialized Hospital medical director with reference number DTH/2265/2024. All the methods and procedures were conducted based on the declaration of Helsinki. The need for written informed consent was waived due to the retrospective nature of the data collection.

3. Results

3.1. Socio‐Demographic Characteristics of the Study Participants

During the study period, 332 pediatric patients' medical records were included and assessed for the detection of the treatment outcome of APSGN at Comprehensive Specialized Hospitals in Northwest Ethiopia. The majority of patients 210 (63.3%) were male children. The most affected age group was between 5 and 9 years, 149 (44.9%). The majority of patients, 207 (62.3%), were from rural areas (Table 1).

Table 1.

Socio‐demographic characteristics of study participants admitted to the pediatric ward with acute post‐streptococcal glomerulonephritis (n = 332).

Variable	Category	Frequency	% (95% CI)
Age (in years)	< 5	73	22.0
	5–9	149	44.9
	10–14	110	33.1
Sex	Male	210	63.3
	Female	122	36.7
Residence	Urban	125	37.7
	Rural	207	62.3

3.2. Clinical Characteristics of the Study Participants

The most common reason for patient presentation was general body swelling 267 (80.4%) (95% C.I: 0.757, 0.846), followed by bloody urine 47 (14.2%) (95% CI: 0.106, 0.184). The duration of infection was less than 2 weeks in 66 (19.9%) children and over 2 weeks in 266 (80.1%). A source of infection was identified in 282 (84.9%) cases, with sore throat as the most common source. According to the World Health Organization (WHO) parameter of nutritional status, most of the patient's nutritional status was undernourished 266 (80.1%). The common complication was hypertension 171 (51.5%). Most of the patients 266 (80.1%) came to the hospital later than 2 weeks of APSGN, and about 235 (70.8%) of patients stayed in the Hospital for longer than 2 weeks (Table 2).

Table 2.

Clinical characteristics of study participants admitted to the pediatric ward with acute post‐streptococcal glomerulonephritis (n = 332).

Variable	Category	Frequency	% (95% CI)
Chief compliant	General body swelling	267	80.4
	Facial swelling	11	3.3
	Oliguria	7	2.1
	Bloody urine	47	14.2
Duration of infection	< 2 weeks	66	19.9
	> 2 weeks	266	80.1
Source of infection	Yes	282	84.9
	No	50	15.1
Length of hospitalization	< 2 weeks	97	29.2
	> 2 weeks	235	70.8
Nutritional status of the patient	Well‐nourished	66	19.9
	Undernourished	266	80.1
Complications	Hypertension	171	51.5
	Encephalopathy	37	11.1
	Heart failure	47	14.2
	Pulmonary edema	41	12.3
	Acute kidney injury	27	8.1
	Othersa	9	2.7

^aSeizure, retinopathy, anemia, hypocalcemia, and acidosis.

3.3. Laboratory Findings of the Study Participants

Urinalysis was done for hematuria and proteinuria for all patients with APSGN infection. About 239 (72%) of patients had both hematuria and proteinuria. Regarding electrolyte analysis, hyperkalemia was found in 129 (38.9%) patients. ASO titer was done for 73 patients, and about 46 (13.9%) had positive results. Creatinine was abnormal for about 47 (14.2%) of patients, and 89 (26.8%) of patients had decreased hemoglobin levels (Table 3).

Table 3.

Laboratory results of study participants admitted to the pediatric ward with acute post‐streptococcal glomerulonephritis (n = 332).

Variable	Category	Frequency	Percent
Urine analysis	Hematuria	66	19.9
	Proteinuria	27	8.1
	Hematuria and proteinuria	239	72.0
Renal function test	Creatinine normal	262	78.9
	Creatinine elevated	47	14.2
	Not done	23	6.9
Electrolyte analysis	Normal	173	52.1
	Hyperkalemia	129	38.9
	Not done	30	9.0
Hemoglobin	Normal	228	68.7
	Decreased	89	26.8
	Not done	15	4.5
Anti‐streptococcal O (ASO) titer	Positive	46	13.9
	Negative	27	8.1
	Not done	259	78.0

3.4. Pharmacologic Management and Treatment Outcome of the Study Participants

Diuretics (e.g., furosemide) were given to about 308 (92.8%) patients in this study, and 132 (39.8%) patients took antibiotics for the treatment of infection before admission. Similarly, 117 (35.2%) patients took angiotensin converting enzyme inhibitors, and 170 (51.2%) patients took calcium channel blockers. Furosemide, Enalapril, and Nifedipine were the common anti‐hypertensive drugs prescribed in the present study (Figure 2).

Figure 2.

Pharmacologic management of the study participants admitted to the pediatric ward with acute post‐streptococcal glomerulonephritis (n = 332).

4. Treatment Outcome

The majority of patients (70.2%) recovered completely (positive treatment outcome), and 99 (29.8%) had died or developed severe complications during hospitalization, including severe hypertension, renal impairment, or other complications related to Acute Post‐Streptococcal Glomerulonephritis (APSGN) at the time of discharge (negative outcome).

4.1. Predictors of the Treatment Outcome of the Study Participants

After controlling for the effects of potentially confounding variables using a multivariable logistic regression model, age, evident source of infection, duration of infection at admission, and acute kidney injury at admission were found to be statistically significant predictors of APSGN treatment outcome.

Children aged 5–9 years had significantly higher odds of negative outcomes (AOR = 2.61, 95% CI: 1.34–5.10, p= 0.006) compared to those under 5 years, while age 10–15 years showed no significant association. Acute kidney injury was linked to worse outcomes (AOR = 1.70, 95% CI: 1.08–2.93, p= 0.032), as was a duration of infection exceeding 2 weeks (AOR = 2.14, 95% CI: 1.06–4.32, p= 0.024). Lastly, the presence of an evident source of infection was strongly associated with negative outcomes (AOR = 2.13, 95% CI: 1.25–5.13) (Table 4).

Table 4.

Predictors of outcomes of patients with acute post‐streptococcal glomerulonephritis (n = 332).

Variable	Category	Treatment outcome		COR (95% CI)	AOR (95% CI)	p value
		Positive	Negative
Age (years)	< 5	59	14	1.00 (Ref)	1.00 (Ref)
	5–9	92	57	2.49 (1.24–4.99)	2.61 (1.34–5.10)	0.006
	10–15	82	28	1.30 (0.61–2.76)	1.44 (0.69–2.97)	0.184
Gender	Male	147	63	1.00 (Ref)	1.00 (Ref)
	Female	86	36	0.98 (0.59–1.59)	1.05 (0.62–1.76)	0.621
Residential area	Urban	84	41	1.00 (Ref)	1.00 (Ref)
	Rural	149	58	0.78 (0.46–1.35)	0.80 (0.48–1.32)	0.425
Acute Kidney Injury at admission	No	152	52	1.00 (Ref)	1.00 (Ref)
	Yes	81	47	1.67 (1.02–2.78)	1.70 (1.07–2.93)	0.032
Duration of infection at admission	< 2 weeks	54	12	1.00 (Ref)	1.00 (Ref)
	> 2 weeks	179	87	2.19 (1.11–4.30)	2.14 (1.06–4.32)	0.024
Severe hypertension	No	190	79	1.00 (Ref)	1.00 (Ref)
	Yes	43	20	1.11 (0.08–1.14)	1.12 (0.09–1.16)	0.071
Evident source of infection	No	26	24	1.00 (Ref)	1.00 (Ref)
	Yes	207	75	2.55 (1.38–4.71)	2.13 (1.25–5.13)	0.002

Note: Negative outcome as an event in logistic regression; statistically significant at p < 0.05, and p values correspond to AOR.

Abbreviations: AOR = adjusted odds ratio, COR = crude odds ratio, reference = baseline category.

5. Discussion

Acute Post‐Streptococcal Glomerulonephritis (APSGN) is a significant public health concern among pediatric age group, often following a streptococcal infection [30]. APSGN is a common cause of acute kidney injury in pediatrics, and studying its treatment outcomes helps quantify the disease's impact on pediatric population health and safety. Understanding the treatment outcomes of APSGN and its predictors is crucial for improving patient management [31]. The objective of the present study was to assess the treatment outcome of patients with APSGN infection and its predictors among medical records of pediatric patients who had been admitted from September 1, 2018 to August 30, 2024, at Comprehensive Specialized Hospitals in Northwest Ethiopia. Assessment of the treatment outcome and predictors for APSGN patients has the greatest importance in boosting positive treatment outcomes and patient safety [11].

Of the 332 patients' medical records assessed for their treatment outcomes of APSGN infection at Comprehensive Specialized Hospitals, 233 (70.2%) (95% CI: 0.649, 0.751) had successful treatment outcomes. This positive treatment outcome in our study was supported by a study conducted in Ethiopia with a success rate of 73.1% in northern Ethiopia [8]. Similarly, 66% of patients recovered from APSGN infection in a study conducted in Sudan in 2012 [32]. The finding of this study was lower than that of the study conducted in Athens, Greece, in which 92% of patients had successful treatment outcomes of APSGN infection [33]. The difference in the treatment outcome of APSGN patients may be due to a slight variation in the study population, study area, or lack of infrastructure, which might result in late presentation to hospital, less attention to patients and/or caregivers to their disease, and low level of care in developing countries. In this study, negative treatment outcomes were defined to include mortality and significant complications such as severe hypertension and persistent kidney dysfunction, offering a more comprehensive evaluation of APSGN morbidity compared to studies that focus solely on survival or crude recovery.

In this study, factors influencing negative treatment outcomes in acute post‐streptococcal glomerulonephritis (APSGN) were identified. Children aged 5–9 years faced worse outcomes than those under 5, supporting prior findings that age is a critical factor in APSGN prognosis. Research in an Ethiopian pediatric cohort also highlighted younger age as linked to poorer outcomes, suggesting age‐dependent vulnerability in disease progression and treatment response [8].

According to this study, the source of infection was a statistically significant risk factor for negative outcomes of APSGN, which was 2.13 times more likely to have negative outcomes of treatment as compared to those who had no evident source of infection. This was in line with the study conducted in Ethiopia, which revealed that the source of infection was four times more likely to be associated with the negative outcomes of APSGN [8], and a study conducted in the Northern Territory, Australia, which found that social and environmental factors were risk factors of APSGN infection [34].

Lack of education, poor nutritional status and water insecurity, overcrowding, climate change, poor personal hygiene, and poverty are all contributing factors to the risk of APSGN infection. A source of infection was identified in 282 (84.9%) cases, with sore throat as the most common source. Whereas, a study conducted in French Polynesia showed that skin infection was the likely source of infection in most of the study participants [35].

Acute kidney injury (AKI) at admission significantly predicts adverse outcomes in patients with APSGN in this study. While literature on AKI as a predictor in APSGN is limited, it is acknowledged as a serious manifestation that correlates with complications and extended hospital stays [36].

Patients who presented later than 2 weeks with APSGN infection to the hospital were 80.1% [95%CI: 0.754, 0.843], while 19.9% [95%CI: 0.157, 0.246] patients came earlier than 2 weeks. This study finding was consistent with the study conducted in northern Ethiopia, which found 82.6% of patients came to the hospital later than 2 weeks of infection, and only 17.4% of patients came earlier than 2 weeks of APSGN infection [8]. A study conducted in Carolina showed that 33% of study participants with APSGN were diagnosed late, and the majority (67%) of participants with APSGN presented early, which was in contrast with this study finding [37]. This might be due to the difference in socio‐economic status, and variation in awareness of patients towards health care and its consequences towards complications of the disease.

The time of presentation to the hospital was also statistically significant, with the negative treatment outcome of APSGN infection in the present study. Patients who present to a hospital late were 2.14 times more likely to be associated with the negative treatment outcomes of APSGN as compared to patients who present early. This is because late diagnosis might lead to complications and severity of the infection, which makes them more exposed to mortality and morbidity associated with negative treatment outcomes. Recent advances in nephrology reclassify post‐streptococcal glomerulonephritis (PSGN) within the broader category of infection‐related glomerulonephritis (IRGN), which encompasses immune‐mediated glomerular injuries that can occur post‐infectious or syn‐infectious. Notably, staphylococcal infection‐associated glomerulonephritis usually occurs during an active infection, contrasting with the typical post‐infectious onset of PSGN. Understanding the timing of glomerular injury and variations in pathogens and host responses is crucial for clinical presentation, histopathology, and prognosis, necessitating careful differentiation in both clinical practice and research [14, 15, 16, 17].

Insights gained from the study can inform healthcare professionals about the best practices for monitoring and managing APSGN in pediatrics, ultimately enhancing patient outcomes. Delays in diagnosis are common in patients with APSGN infection, especially if visible bloody urine or hematuria is not a reason for presentation [37]. Strengthening preventive strategies, such as improved access to timely treatment of streptococcal infections, may help to enhance the treatment outcome of APSGN in pediatrics.

5.1. Strengths and Limitations of This Study

• The study design allows for the examination of a greater number of patients over an extended period, providing a comprehensive view of treatment outcomes in pediatric patients with APSGN.

• The present study used a robust questionnaire and experienced data collectors to extract data from patients' medical records.

• The retrospective nature of the study could not address some pertinent variables that were not included during the registration of patients for treatment.

• As the study was conducted at a single hospital, the generalizability of the findings to the wider population or other healthcare settings may be limited.

• Another limitation of the study is the inconsistent availability of complement levels (C3 and C4) in medical records, preventing evaluation of their levels at presentation and normalization during follow‐up in acute post‐streptococcal glomerulonephritis.

6. Conclusion and Recommendations

Generally, 332 pediatric patients' medical records were involved in the present study, and more than half of the patients recovered completely and had positive outcomes. The most common reason for presentation was general body swelling. The majority of patients came after 2 weeks of infection and stayed at the hospital for more than 2 weeks. The predictors of the treatment outcome of APSGN in patients were age, duration of infection, source of infection, and length of stay in the hospital. Treating physicians should order laboratory investigations timely, and clinical pharmacists should monitor patients regularly to increase treatment outcomes and prevent complications. Caregivers/parents should bring their children to the hospital as early as possible when they are sick and should adhere to physicians' and/or pharmacists' instructions. Future studies should focus on longitudinal prospective studies that consider presentation types such as rapidly progressive glomerulonephritis (RPGN) and the requirement for hemodialysis. Future research could also investigate potential differences in the distribution of skin versus throat infections among children based on their place of residence.

Author Contributions

Tilaye Arega Moges: conceptualization, investigation, writing – original draft, methodology, writing – review and editing, validation, formal analysis, supervision, data curation. Samuel Berihun Dagnew: methodology, writing – review and editing, project administration, formal analysis, software, writing – original draft, funding acquisition, investigation, visualization. Yibeltal Tilaye Yayeh: investigation, writing – review and editing, formal analysis, resources, supervision, data curation, conceptualization, methodology, writing – original draft, validation. Samuel Agegnew Wondm: methodology, visualization, writing – review and editing, software, formal analysis, funding acquisition, investigation, resources. Fisseha Nigussie Dagnew: investigation, validation, visualization, formal analysis, writing – review and editing, resources. Getachew Yitayew Tarekegn: investigation, writing – review and editing, visualization, methodology, software, formal analysis, resources. Mekdes Kiflu: investigation, writing – review and editing, visualization, software, project administration. Asres Agegnehu Worku: writing – review and editing, visualization, validation, methodology, software, project administration, resources. Mulugeta Ashagrie Bekahagn: investigation, writing – original draft, writing – review and editing, methodology, project administration, supervision, data curation, resources, funding acquisition. Kale Gubae: investigation, methodology, writing – review and editing, visualization, data curation, formal analysis, software.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Any data concerning this manuscript may be available upon reasonable request of the corresponding author.