Department of Pathology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureş, Romania;
Rom J Morphol Embryol. 2020 Apr-Jun;61(2):535-544. doi: 10.47162/RJME.61.2.24.
The continuous flow left ventricular assist device (cf-LVAD) is the life-saving solution for patients with end-stage global heart failure. We present the case of a young patient with biventricular dilated cardiomyopathy, who had a cf-LVAD implantation and died as result of progressive renal failure. In the first year after implantation, he suffered repeated strokes and episodes of pneumonia with Klebsiella pneumoniae and Escherichia coli. The patient had hypertension, which was kept under control with angiotensin-converting enzyme (ACE) inhibitors and beta-blockers. After multiple bleeding episodes, the patient died at 21 months after the LVAD implant. At autopsy, parenchymatous brain hemorrhage was found to be associated with pulmonary hemorrhages. The unexpected features related to mesangioproliferative and extracapillary glomerulonephritis, with focal glomerulosclerosis. The proliferated parietal cells of Bowman's capsule proved to express cluster of differentiation 44 (CD44), whereas remnant podocytes and mesangial cells showed Wilms tumor 1 (WT1) positivity. Since CD44 might be involved in fibrogenesis, but ACE inhibitors can exert a protective role against glomerular deterioration, we performed a synthesis of literature data which enabled us to propose a hypothesis with a potential clinical impact. We conclude that, in patients with LVAD implants, high blood pressure and high serum level of angiotensin II, the association between ACE inhibitors and anti-CD44 agents might exert glomerular protection and increase the survival time. Experimental studies are necessary to support our hypothesis and to explain the mechanism of possible glomerulopathy installed after LVAD implant.
持续流动左心室辅助装置（cf-LVAD）是终末期全球心力衰竭患者的救命解决方案。我们介绍了一位年轻的双心室扩张型心肌病患者的病例，他接受了 cf-LVAD 植入术，并因进行性肾衰竭而死亡。植入后第一年，他反复发生中风，并发生肺炎克雷伯菌和大肠杆菌感染。该患者患有高血压，通过血管紧张素转换酶（ACE）抑制剂和β受体阻滞剂将其控制在正常范围内。多次出血后，该患者在 LVAD 植入后 21 个月死亡。尸检时发现，实质性脑出血与肺出血有关。出乎意料的特征与系膜增生性和毛细血管外肾小球肾炎有关，伴有局灶性肾小球硬化。增生的鲍曼囊壁细胞表达分化群 44（CD44），而残留的足细胞和系膜细胞显示 Wilms 瘤 1（WT1）阳性。由于 CD44 可能参与纤维化形成，但 ACE 抑制剂可以发挥保护肾小球恶化的作用，因此我们综合了文献数据，提出了一个具有潜在临床影响的假设。我们得出结论，在接受 LVAD 植入的患者中，高血压和血管紧张素 II 水平升高，ACE 抑制剂和抗 CD44 药物的联合应用可能发挥肾小球保护作用，并延长生存时间。需要进行实验研究来支持我们的假设，并解释 LVAD 植入后可能发生的肾小球病的机制。
