Indian J Nephrol
Transcript of Indian J Nephrol
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Indian J Nephrol. 2011 Apr-Jun; 21(2): 116119.
doi: 10.4103/091-406!."2141
#$%I&: #$%3132331
Postinfectious glomerulonephritis: Is there a role for steroids?A. '. apadia $. #andaandA. *. +o,o1
Auhor inoraion %opri,h and iene inoraion
5o o:
Abstract
The role of steroids in treatment of postinfectious glomerulonephritis (PIGN) has been
controversial. The reason for such controversy is the risk of infection relapse associated
with steroid therapy. teroids may have a place in the treatment of resistant cases where
renal function does not improve despite aggressive antibiotic therapy as well as in
patients with crescentic form of PIGN. !e report a case of a "# year$old %aucasian man
who was diagnosed with methicillin$resistantStaphylococcus aureus(&') bacteremia
resulting in acute Ig dominant PIGN that failed to respond to antibiotic treatment
alone but responded significantly to steroids in addition to antibiotics. This anecdotal
e*perience suggests that steroids could be considered in con+unction with antibiotic
therapy for the treatment of refractory cases of PIGN or crescentic form of PIGN. &ore
studies with long$term follow$up of patients treated with steroids in addition to
antimicrobial agents are re,uired to ,uantify the risk of infection relapse with steroidtherapy.
Keywords: ðicillin$resistantStaphylococcus aureus postinfectious
glomerulonephritis postinfectious glomerulonephritis steroids
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Introduction
Glomerulonephritis occurring as a conse,uence of &' infection was first reported by
-oyama in ##/.01 ubse,uently more cases were reported that elaborated the
histopathology and pathogenesis including role of taphylococcal cell envelope antigen.
02341 5owever there are only a few case reports that focus on the treatment of this
entity. The roles of steroids have been controversial with regard to their indications
timing and long$term complications including relapse of infection.0/61 !e report a case
of post$&' Ig dominant PIGN that re,uired treatment with steroids in addition to
antibiotic therapy.
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Case Report
http://dx.doi.org/10.4103%2F0971-4065.82141http://www.ncbi.nlm.nih.gov/pubmed/?term=Kapadia%20AS%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Panda%20M%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Panda%20M%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Fogo%20AB%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Fogo%20AB%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/#ref1http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/#ref2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/#ref4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/http://www.ncbi.nlm.nih.gov/pubmed/?term=Kapadia%20AS%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Panda%20M%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Fogo%20AB%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/#ref1http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/#ref2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/#ref4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/#ref6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/http://dx.doi.org/10.4103%2F0971-4065.82141 -
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@uring this time period patient was evaluated for the cause of acute renal failure. 5is
urine analysis at this point revealed red blood cells /6:hpf a few dysmorphic red blood
cells !C%s D:hpf no eosinophils proteinuria with urine protein to creatinine ratio
2.#4 fractional e*cretion of sodium =.6= and fractional e*cretion of urea 24./A urine
microscopic e*am revealed few muddy brown casts. The urine color was brown andspecific gravity was normal. 5is renal function did not return to baseline after a few days
of hemodialysis. %onsidering the possibility of acute glomerulonephritis the patient
underwent %T guided biopsy of the right kidney which revealed Ig dominant PIGN
with e*tensive acute tubular in+ury and acute interstitial nephritis. 8ight microscopy
showed glomeruli with mild to moderate increase in the mesangial matri* and
cellularity with cellular crescents in 2 of the " glomeruli sampled and fibrinoid necrosis
in one of these. In addition rare hump shaped deposits were visuali7ed overlying the
glomerular basement membrane in the capillary notch area 0?igure "a1.
%orrespondingly immunofluorescence (I?) microscopy showed 2E mesangial and
segmental capillary loop staining for Ig and %" while IgG was negative 0?igure "b1.
Flectron microscopy showed scattered mesangial deposits and rare subepithelial hump
type deposits 0?igure "c1. These findings were characteristic of Ig dominant
postinfectious glomerulonephritis. The biopsy also showed acute tubular in+ury and a
hypersensitivity drug induced acute interstitial nephritis with widespread tubultitis and
interstitial nephritis in areas away from the crescents.
?igure "
(a) Glomerulus with small cellular crescent fibrinoid necrosis (top) and small hump$shaped deposit (arrow) (onesH silver stain 4;;). (b) Immunofluorescence showed 2E
Ig predominantly mesangial and segmental capillary wall staining ...
The patient received pulse doses of steroids followed by oral steroids. 5e was discharged
with arrangements to receive intravenous antibiotics and hemodialysis. 5is creatinine at
the onset of the steroid therapy was /./ mg:dl which improved after 2 weeks of
treatment at which point he was removed off hemodialysis. Jn follow up at three
months and at one year his creatinine was .= and ." mg:dl respectively.
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Discussion
Post$&' infection glomerulonephritis has been well documented in apan. 5owever
as the incidence of &' infection increases globally and the association between &'
infection and Ig dominant glomerulonephritis is now clear more cases are being
reported from all countries including the >nited tates. %linical manifestations of PIGN
following &' infection include acute renal failure developing within 43; weeks after
the onset of infection.0/1 -idney biopsy should be considered in all patients with '?
and documented infection when PIGN is suspected to confirm the diagnosis anddetermine the need for steroid therapy especially when renal function does not improve
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/figure/F3/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/figure/F3/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/figure/F3/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/figure/F3/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/#ref5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/figure/F3/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/figure/F3/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/figure/F3/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/figure/F3/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132331/#ref5 -
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with antibiotic treatment as patients with presence of crescents on renal biopsy usually
re,uire treatment with steroids. It may be difficult to differentiate PIGN from Ig
nephropathy. In classic acute PIGN cases there is an acute e*udative proliferative
response with fre,uent polymorphonucler leucocytes (P&Ns) infiltrating the glomeruli.
In more chronic cases there is less P&N infiltration. Flectron microscopy can then behelpful in demonstrating the typical subepithelial humps characteristic of postinfectious
glomerulonephritis contrasting the lack of such deposits in usual Ig nephropathy.041
The coe*isting IN may also have contributed to renal dysfunction as in our patient. In
such instances it is always difficult to ,uantify the response obtained in terms of
improvement in renal function with respect to different disease processes affecting the
kidneys.
There have been case reports of successful treatment of PIGN following &' infection
with antimicrobial agents only.06=1 study done in apan included eight patientsA si* of
which were treated with antibiotics only and the rest of the patients received steroids.061The patients who received steroids only had poor outcome secondary to relapse of the
infection. Two of the si* patients who received steroid therapy were diagnosed after five
months and three months of their presentations respectively and were not on antibiotic
treatment when they received steroid therapy. s these patients developed
glomerulonephritis a few months after the initial infection it may be possible that these
patients had persistent &' activity. The patients who were treated with antibiotics
only responded very well. Therefore these cases do not reflect the refractory cases that
fail to respond to antimicrobial agents only. Jn the other hand there are several case
reports of successful treatment of resistant cases of PIGN following &' infection with
steroids without any relapse of the infection.0=91 The role of steroids in these patients
could be e*plained by the pathogenesis of PIGN which involves the interaction of the
host immune system with bacterial superantigen.
Cased on our e*perience we would like to suggest a possible role of steroid therapy in
PIGN who fail to respond to antibiotic therapy alone and in patients with crescentic form
of PIGN. It is also possible that the presence of IN contributed to steroid
responsiveness in our patient. The benefits of steroid therapy in terms of impact on
,uality of life may be considered significant as it may alleviate the need for long$term
hemodialysis. 5owever more studies are needed to define the role of steroids and
compare the benefits with the risks associated with such therapy.
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FootnotesSource of Support:Nil
Conflict of Interest:None delared.
5o o:
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