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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: &ethicillin$resistantStaphylococcus aureus postinfectious

glomerulonephritis postinfectious glomerulonephritis steroids

5o o:

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.

5o o:

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.

5o o:

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.

5o o:

FootnotesSource of Support:Nil

Conflict of Interest:None delared.

5o o:

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