Glomerulonephritis causing acute renal failure during the course of bacterial infections. Histological varieties, potential pathogenetic pathways and treatment

Abstract

To illustrate diagnostic approaches, potential pathogenetic differences, epidemiological implications and therapeutic dilemmas posed by glomerulonephritis (GN) with acute renal failure (ARF) complicating bacterial infections, we analyzed the course of four male patients, aged 53-71 years, who developed GN and ARF following bacterial infections. The first two patients developed GN with immunoglobulin A (IgA) deposits after infections with hospital-acquired methicillin resistant Staphylococcus aureus (MRSA). Clinical, serologic and histological features, classification of GN and treatment differed between the two patients. In the first patient, serological features (transient hypocomplementemia, normal serum protein electrophoresis) and histological findings were consistent with typical post-infectious GN. Treatment with antibiotics alone resulted in normalization of the renal function despite the severity of ARF, which required temporary hemodialysis. In the second patient, serological features (normal serum complement, polyclonal elevation of gamma globulins) and histological picture of the kidneys were characteristic of IgA nephropathy with fibrocellular crescents, and skin histology was consistent with vasculitis. Cyclophosphamide and corticosteroids were added to the antibiotics, with partial improvement of the renal failure. The third patient developed simultaneous acute rheumatic fever and post-streptococcal GN causing severe ARF requiring hemodialysis. Complete recovery of ARF and migratory polyarthritis followed initiation of corticosteroids. The fourth patient developed ARF and cerebral vasculitis following a prolonged course of Streptococcus mutans endocarditis with delayed diagnosis. He also developed multiple serological abnormalities including elevated titers of antineutrophil cytoplasmic antibodies (ANCA), antinuclear antibodies (ANA), anti-phospholipid antibodies, rheumatoid factor, and modest hypocomplementemia. Kidney biopsy revealed ANCA-mediated focal GN with 10% crescents and acute interstitial nephritis. Treatment with cyclophosphamide plus corticosteroids, but not with antibiotics alone, resulted in resolution of both the ARF and the features of cerebral vasculitis. GN following bacterial infections may have various pathogenetic mechanisms, presents complex diagnostic challenges, may be preventable in the case of hospital-acquired MRSA, and, in addition to antibiotics, may require immunosuppressive therapy in carefully selected and monitored cases.

Clinicopathologic Features of IgA-Dominant Infection-Associated Glomerulonephritis: A Pooled Analysis of 78 Cases

“…One study was excluded due to the presence of idiotypic IgAN combined with infecion [11]; 3 references were excluded because of publication type (i.e., review) [2,12,13]; and 3 studies were excluded due to unavailable relevant original data [14,15,16]. Finally, 28 eligible reports concerning IgA-dominant IAGN were obtained and reviewed again based on the exclusion criteria [4,5,6,7,8,9,10,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37]. …”

“…We also investigated the pathological presentation, treatment modalities, and clinical outcomes. Complete information from 85 patients was collected, of which 4 patients were excluded because they had not performed a renal biopsy [4], 2 were excluded due to the lack of IgA deposition on IF and 1 was excluded due to a diagnosis of diffuse proliferative IgA nephropathy [26]. Ultimately, 78 eligible cases were selected into our study (fig.…”

Glomerulonefritis rápidamente progresiva asociada a endocarditis afebril y anca anti-proteinasa 3

“…La literatura recoge 16 casos de ANCA positivos en pacientes con endocarditis y glomerulonefritis aguda en biopsia renal (Tabla 1), de los cuales diez son ANCA anti-PR3 positivos [5][6][7][8][9][10][11][12][13] , dos anti-mieloperoxidasa 11,14 y en cinco de ellos no se especifica el tipo [15][16][17][18][19] . Los ANCA anti-PR3 se pueden elevar en enfermedades del tejido conectivo e infecciones crónicas como endocarditis subagudas bacterianas, tuberculosis o infección por el virus de la hepatitis B o C 5 , así como en ancianos.…”

Favorable Outcome of Crescentic IgA Nephropathy Associated with Methicillin-ResistantStaphylococcus aureusInfection

“…8 Since then, there have been 34 cases of this entity reported in the English literature. [7][8][9][10][11][12][13][14][15][16][17][18][19] All patients were adults with a mean age of 59 years (range = 21-89 years). Twenty-six patients (76%) had MRSA, 5 (15%) had methicillinsensitive S. aureus, and 3 (9%) had S. epidermidis.…”

“…20 Glomerular crescent formation may complicate this new type of poststaphylococcal glomerulonephritis and there are nine cases of this entity reported in the literature. 9,12,15,18,19 The clinical characteristics of patients with at least 10% crescents on renal biopsy are summarized in Table 1. All patients were infected with MRSA.…”