感染性心内膜炎的肾脏损害

目的分析感染性心内膜炎(IE)致肾脏损害的诊治及预后情况,旨在提高对该类疾病的认识。方法回顾性分析北京协和医院1983年至2004年12月155例IE的临床特点及其中4例的肾组织学表现,以及治疗和预后情况。应用卡方分析、t检验或Spearman等级相关分析方法进行统计分析。结果IE伴肾损害137例(88.4%),男女比1.4:1,发病年龄(38±17)岁,肾损害前病程为(4.8±5.9)月。肾损害表现包括无症状血尿和(或)蛋白尿(71.0%)、急性肾炎综合征(6.5%)、肾病综合征(2.6%)、急进性肾炎综合征(1.3%)、肾栓塞(1.3%)、单纯白细胞尿(3.2%)、非IE直接所致肾损害(2.6%)。急性肾功能不全14例,病因包括肾小球肾炎5例、急性间质性肾炎1例、肾栓塞1例、急性心衰5例、抗生索不良反应2例。肾组织检查4例,分别为弥漫增生性肾小球肾炎、膜性肾病Ⅱ期、膜增生性肾小球肾炎及Ⅱ型新月体肾炎各1例。所有病例均予抗生素治疗,其中3例停用引起肾损害的抗生素;28例(20.4%)予手术治疗;5例(3.6%)予糖皮质激素和/或免疫抑制剂治疗,其中2例予甲基泼尼松龙冲击治疗;1例予抗凝治疗。155例中7例(4.5%)死亡。伴肾损害137例中60例(43.8%)肾损害完全恢复。急性肾功能不全14例中12例(85.7%)血肌酐值恢复正常。统计分析表明,在积极治疗情况下,有无肾损害及不同程度肾损害的IE患者的预后差异无统计学意义。结论IE致肾损害很常见,多为无症状血尿和(或)蛋白尿,肾栓塞、急性肾炎综合征、肾病综合征及急进性肾炎综合征也可出现。对IE所致急进性肾小球肾炎患者,在感染得到有效控制情况下,可酌情给以糖皮质激素、免疫抑制剂包括甲基泼尼松龙冲击治疗。

Renal lesion associated with infectious endocarditis

Objective To analyse renal lesions associated with infectious endocarditis (IE). Methods Renal lesions associated with IE were reviewed. One hundred and fifty-five cases of IE were admitted to Peking Union Medical College Hospital from 1983 to 2004. C-square, t-test and Spearman's rank correlation analysis were performed. Results One hundred and thirty-seven(84.4%) cases of renal lesions associated with IE with an average age of 38 were found. The ratio of male to female was 1.4 and the period of pre-renal lesion was 4.8 months. Renal lesions included asymptomatic hematuria and/or proteinuria (71.0%), acute nephritic syndrome (6.5%), nephrotic syndrome (2.6% ), rapid progressive glomerulonephritis (1.3% ), renal embolism (1.3% ), isolated pyuria(3.2%), renal lesion not directly related to IE(2.6%). Acute renal insufficiency in 14 cases were caused by glomerulonephritis (5 cases), acute interstitial nephritis (5 cases), renal embolism(1 case), acute heart failure(5 cases) and the adverse effect of antibiotics (2 cases). Renal biopsy was taken in four patients. One diffuse proliferative glomerulonephritis, one membranous glomerulonephritis, one membrane-proliferative glomerulonephritis and one crescentic glomerulonephritis were found. All patients received antibiotic therapy and three of them stopped taking antibiotics, which was suspected to cause renal lesion. 20.4% cases received surgical therapy. 3.6% were treated with corticosteroid and/or immunoimpressive drugs and two cases of them were treated with intravenous bolus methylprednisolone. One case recieved anticoagulant therapy. 4.5% cases died. 43.8% cases with renal lesions were cured and 85.7% serum creatinine level decreased to normal. Statistical analysis showed that active treatment made no improvement on neither patients with or without renal lesion nor patients with different severity of renal lesion. Conclusions Renal lesions associated with IE are common. Most are asymptomatic hematuria and/or proteinuria. Acute nephritic syndrome, nephrotic syndrome, rapid progressive glomerulonephritis, renal embolism may also occur. It maybe appropriate to treat with corticosteroid, immunopressive drugs or intravenous bolus methylprednisolone for patients with rapid progressive glomerulonephritis under successful management of infective endocarditis.