Renal disease in the setting of infective endocarditis or an infected ventriculoatrial shunt
- Jai Radhakrishnan, MD, MS
Jai Radhakrishnan, MD, MS
- Professor of Medicine
- Columbia University Medical Center
- Section Editors
- Richard J Glassock, MD, MACP
Richard J Glassock, MD, MACP
- Editor-in-Chief — Nephrology
- Section Editor — Glomerular Diseases
- Emeritus Professor
- The David Geffen School of Medicine at UCLA
- Fernando C Fervenza, MD, PhD
Fernando C Fervenza, MD, PhD
- Section Editor — Glomerular Diseases
- Professor of Medicine
- Mayo Clinic College of Medicine
RENAL DISEASE IN INFECTIVE ENDOCARDITIS
Patients with infective endocarditis (IE) can develop several forms of renal disease: a bacterial infection-related immune complex-mediated glomerulonephritis (GN), renal infarction from septic emboli, and renal cortical necrosis [1-3]. In addition, a drug-induced acute interstitial nephritis or, with aminoglycosides, acute kidney injury (due to acute tubular necrosis) can develop as a result of treating the infection. (See "Renal infarction" and "Clinical manifestations and diagnosis of acute interstitial nephritis" and "Manifestations of and risk factors for aminoglycoside nephrotoxicity".)
The frequency of renal involvement was illustrated in a retrospective study of over 200 consecutive episodes of bacterial endocarditis . Approximately one-third of patients developed acute kidney injury (of any cause), a complication observed most often among older patients and those with Staphylococcus aureus infection. In a separate series of patients with IE-associated GN, acute kidney injury was the most common clinical presentation .
Clinical features and renal biopsy findings — The most common organism in IE-associated GN is S. aureus, which is seen in 56 percent of cases; Streptococcus species are the next most common. Less common organisms include Bartonella henselae, Coxiella burnetii, Cardiobacterium hominis, and Gemella. In 9 percent of patients with IE-associated GN, no organism could be cultured. One-half of affected patients do not have a known risk factor; in the remainder, common comorbidities included cardiac valve disease (30 percent), intravenous drug use (29 percent), hepatitis C (20 percent), and diabetes (18 percent). The cardiac valve infected was tricuspid in 43 percent, mitral in 33 percent, and aortic in 29 percent of patients in the largest series described . There are a few case reports of patients with IE and GN who developed pulmonary hemorrhage, potentially mimicking other systemic diseases such as antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis and antiglomerular basement membrane (anti-GBM) autoantibody disease [6,7]. (See "Differential diagnosis and evaluation of glomerular disease", section on 'Acute glomerulonephritis and pulmonary hemorrhage'.)
Acute kidney injury is the most common clinical presentation (79 percent), and almost all patients have hematuria (97 percent) . Features of the acute nephritic syndrome were seen in a minority (10 percent), as was nephrotic syndrome (6 percent); 53 percent of patients had reduced C3 complement, and 19 percent had reductions in C4 complement, suggesting activation of the alternative complement pathway. ANCA (usually directed at myeloperoxidase or lactoferrin) may be positive in up to one-third of patients ; some patients also have a positive rheumatoid factor, and rare patients are positive for anti-GBM autoantibodies.
In the largest series, crescentic GN was the most common pattern seen on renal biopsy specimens by light microscopy (53 percent) . Diffuse proliferative GN was also a common finding (33 percent), and focal proliferative GN and mild mesangial proliferative GN were seen in a few patients. In addition to GN, the majority of patients showed tubular injury (86 percent) and interstitial inflammation (88 percent). By immunofluorescence microscopy, C3 was present in 94 percent of cases, immunoglobulin staining was observed in less than one-third of biopsies, and IgA-dominant (or codominant with IgG) staining was seen in 17 percent. A significant proportion of biopsies met the criteria for pauci-immune GN by immunofluorescence (44 percent). On electron microscopy, 90 percent of biopsies showed deposits, most commonly in the mesangial area (84 percent), followed by the subendothelial area (45 percent). Only a minority had subepithelial "humps," which are deposits that are classically seen in infection-related GN (14 percent).
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- RENAL DISEASE IN INFECTIVE ENDOCARDITIS
- Clinical features and renal biopsy findings
- Treatment and outcome
- RENAL DISEASE WITH INFECTED VENTRICULAR SHUNTS
- Clinical manifestations and histopathology
- Treatment and prognosis
- Infective endocarditis
- Infected ventriculovascular shunts