Zeledon Jorge I, McKelvey Robin L, Servilla Karen S, Hofinger Diedre, Konstantinov Konstantin N, Kellie Suzan, Sun Yijuan, Massie Larry W, Hartshorne Michael F, Tzamaloukas Antonios H
Section of Nephrology, Renal Section (111C), New Mexico Veterans Affairs Health Care System, Albuquerque, NM, USA.
Int Urol Nephrol. 2008;40(2):461-70. doi: 10.1007/s11255-007-9323-6.
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.
为了阐明由细菌感染并发急性肾衰竭（ARF）的肾小球肾炎（GN）所带来的诊断方法、潜在的发病机制差异、流行病学影响及治疗困境，我们分析了4例年龄在53 - 71岁之间的男性患者的病程，这些患者在细菌感染后发生了GN和ARF。前两名患者在医院获得性耐甲氧西林金黄色葡萄球菌（MRSA）感染后出现了伴有免疫球蛋白A（IgA）沉积的GN。两名患者在临床、血清学和组织学特征、GN的分类及治疗方面存在差异。在第一名患者中，血清学特征（短暂性低补体血症、正常血清蛋白电泳）和组织学发现与典型的感染后GN一致。尽管ARF严重，需要临时血液透析，但仅用抗生素治疗就使肾功能恢复正常。在第二名患者中，血清学特征（正常血清补体、γ球蛋白多克隆升高）和肾脏组织学表现为伴有纤维细胞性新月体的IgA肾病特征，皮肤组织学与血管炎一致。在抗生素治疗基础上加用了环磷酰胺和皮质类固醇，肾衰竭有部分改善。第三名患者同时发生急性风湿热和链球菌感染后GN，导致严重ARF需要血液透析。开始使用皮质类固醇后，ARF完全恢复，游走性多关节炎也随之缓解。第四名患者在变形链球菌心内膜炎病程延长且诊断延迟后发生ARF和脑血管炎。他还出现了多种血清学异常，包括抗中性粒细胞胞浆抗体（ANCA）、抗核抗体（ANA）、抗磷脂抗体、类风湿因子滴度升高以及轻度低补体血症。肾脏活检显示ANCA介导的局灶性GN伴10%新月体形成和急性间质性肾炎。使用环磷酰胺加皮质类固醇治疗，而不是仅用抗生素治疗，使ARF和脑血管炎的症状均得到缓解。细菌感染后的GN可能有多种发病机制，带来复杂的诊断挑战，对于医院获得性MRSA感染可能是可预防的，并且除抗生素外，在经过精心选择和监测的病例中可能还需要免疫抑制治疗。
