Crescentic glomerulonephritis associated with infective endocarditis: renal recovery after immediate surgical intervention |
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Authors: | K Osafune H Takeoka H Kanamori H Koshiyama K Hirose M Hanada R Mimura F Ando K Kanatsu |
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Institution: | (1) Department of Life Science (Biology), The University of Tokyo, 3-8-1 Komaba, Meguro-ku, Tokyo 153-8902, Japan Tel. +81-3-5454-6632; Fax +81-3-5454-4330, JP;(2) Division of Nephrology, Department of Internal Medicine, Hyogo Prefectural Amagasaki Hospital, Hyogo, Japan, JP;(3) Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki Hospital, Hyogo, Japan, JP |
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Abstract: | A 57-year-old man was referred to our hospital because of acute cardiac failure and acute renal insufficiency. Laboratory
data showed elevation of serum immune complex levels and antineutrophil cytoplasmic antibody (ANCA) titers, with cytoplasmic
pattern (C-ANCA) on indirect immunofluorescence (IIF), and proteinase 3 specificity (PR3-ANCA) on solid-phase enzyme-linked
immunosorbent assay (ELISA). Hemodialysis therapy was initiated, and this relieved the symptoms of cardiac failure. Echocardiography
revealed three-grade aortic insufficiency and two large floating vegetations on the aortic valve. Considering the risk of
embolism, we immediately performed aortic valve replacement and surgically removed the vegetations, subsequently giving antibiotic
therapy. Six weeks after the operation, the patient's renal function showed marked improvement and the serological abnormalities,
except for ANCA titers, had normalized, resulting in no need for dialysis. A renal biopsy specimen revealed diffuse proliferative
glomerulonephritis (GN) with crescents including more than 50% of glomeruli, and granular deposits of IgM, C3, and C1q on
immunofluorescence. ANCA titers remained high, but the patient's renal function has been stable, indicating a discrepancy
between ANCA titers and his clinical course. In this patient, treatment by immediate surgical intervention, performed during
the acute phase with active GN and highly reduced renal function, led to dramatic renal recovery. This case suggests that
surgical removal of vegetations in the early stage of crescentic GN may result in a good renal outcome in patients with rapidly
progressive GN associated with endocarditis. Although it has been suggested that ANCA may have some relationship to GN in
endocarditis, in this patient, its pathogenetic significance is questionable.
Received: March 10, 2000 / Accepted: May 23, 2000 |
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Keywords: | Infective endocarditis Crescentic glomerulonephritis Cardiac surgery C-ANCA PR3-ANCA |
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