Skip to main content

Patients with emm1/T1 serotype invasive group A streptococci infections demonstrated more renal failure than patients with other serotypes: perhaps we should consider some confounders

We read with great interest the article by Björck et al. who concluded that in their study of critically ill patients with invasive group A streptococcal (iGAS) infections, emm1/T1 was the most dominant serotype and that patients with that serotype demonstrated more circulatory and renal failure than patients with other serotypes of iGAS [1]. We would like to make some comments. Intravenous immunoglobulins (IVIGs) are often used as a part of the treatment of iGAS [1]. We noted that 52% of the emm1/T1 serotype patients received IVIGs as compared to 28% of the patients with other serotypes [1]. The incidence of acute kidney injury (AKI) with IVIGs stabilized with glucose, maltose, d-sorbitol, mannitol, glycine, or l-proline has been found to be lower than that with sucrose-stabilized products [2]. AKI induced by sucrose-containing IVIGs is likely related to the toxic action of sucrose on the nephron, whereby excess sucrose in the kidney causes osmotic nephrosis [2, 3]. Whilst osmotic nephrosis has been reported with sucrose-free IVIGs, the incidence is much lower because the levels of these agents can be closely regulated by enzymes within the kidney [2, 4]. Similarly to sucrose, excessive glucose accumulation can have deleterious effects on the proximal tubules [5] and, since intravenous glucose infusion is known to produce a rapid increase in blood glucose and insulin levels in normal subjects, diabetic patients are at particular risk of AKI following administration of glucose-stabilized IVIGs [2]. The incidence of diabetes mellitus is not reported in the paper of Björck et al. [1]. It is possible that the increase of AKI in the emm1/T1 serotype group was due to IVIGs. It would be very interesting to know if the IVIGs given to patients in this study were sucrose-stabilized.

Availability of data and materials

Not applicable.

Abbreviations

iGAS:

Invasive group A streptococci

IVIGs:

Intravenous immunoglobulins

AKI:

Acute kidney injury

References

  1. Björck V, Påhlman LI, Bodelsson M, et al. Morbidity and mortality in critically ill patients with invasive group A streptococcus infection: an observational study. Crit Care. 2020;24:302. https://doi.org/10.1186/s13054-020-03008-z.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Dantal J. Intravenous immunoglobulins: in-depth review of excipients and acute kidney injury risk. Am J Nephrol. 2013;38(4):275–84. https://doi.org/10.1159/000354893.

    Article  CAS  PubMed  Google Scholar 

  3. Lin RY, Rodriguez-Baez G, Bhargave GA, Lin H. Intravenous gammaglobulin-associated renal impairment reported to the FDA: 2004–2009. Clin Nephrol. 2011;76:365–72.

    Article  CAS  Google Scholar 

  4. Orbach H, Tishler M, Shoenfeld Y. Intravenous immunoglobulin and the kidney – a two-edged sword. Semin Arthritis Rheum. 2004;34:593–601.

    Article  CAS  Google Scholar 

  5. Ochs HD, Siegel J. Stabilizers used in intravenous immunoglobulin products: a comparative review. Pharm Pract News, 2010.

Download references

Acknowledgements

We would like to thank Dr. Melissa Jackson for the critical review of the manuscript.

Funding

None.

Author information

Authors and Affiliations

Authors

Contributions

PMH, SR, and DDB designed the paper. All authors participated in drafting and reviewing. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Patrick M. Honore.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare to have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Honore, P.M., Barreto Gutierrez, L., Kugener, L. et al. Patients with emm1/T1 serotype invasive group A streptococci infections demonstrated more renal failure than patients with other serotypes: perhaps we should consider some confounders. Crit Care 24, 473 (2020). https://doi.org/10.1186/s13054-020-03180-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13054-020-03180-2