感染性心内膜炎合并新月体肾炎2例及文献复习

Infective endocarditis accompanying crescentic glomerulonephritis: A report of two cases and review of the literature

目的探讨感染性心内膜炎造成的新月体肾炎治疗和预后。方法对本科收治的2例感染性心内膜炎并发新月体肾炎患者的临床及病理特点、治疗方法和预后进行分析,并复习国内外相关文献。结果两例患者均为中青年男性,有先天性心脏瓣膜病史,经心脏B超及血培养检查确诊为感染性心内膜炎。例1:尿蛋白3+,潜血3+,24h尿蛋白定量3.8g,血肌酐最高673.5μmol/L;肾活检显示31个完整肾小球,23个新月体形成(74.2%,11个细胞性)。给予青霉素抗感染、血液透析治疗,并给予激素80mg静滴3d后改为40mg口服,1月后肾功能仍未恢复,激素500mg冲击治疗3d后改为40mg口服,逐渐减量,肾功能恢复正常,脱离透析,随访2年余,复查血肌酐(Scr)68μmol/L,尿常规蛋白1+,潜血-。例2:尿蛋白1+,潜血-,血肌酐最高216.3μmol/L,肾活检显示26个完整肾小球,14个小球新月体形成(53.8%,纤维性为主),予长期抗感染治疗,未予激素治疗,行瓣膜置换术后肾功能恢复正常;随访2年,Scr 86.6μmol/L,尿常规(-)。结论对于细胞性新月体为主的患者,建议给予激素治疗,甚至激素冲击治疗;对于纤维性新月体较多的患者可以只予抗感染及换瓣等清除感染灶治疗;此两例预后均较好。

Objective To study the treatment of infective endocarditis-induced crescentic glomerulonephritis and its prognosis. Methods Clinicopathological characteristics, treatment and prognosis of 2 patients with infective endocarditis acompanying crescentic glomerulonephritis admitted to our department were analyzed with the related literature reviewed. Results The 2 patients were adult males with a history of congenital vulvular disease of heart（VDH） and diagnosed with infective endocarditis according to B-ultrasonography and blood culture. Laboratory test showed that the proteinuria and occult blood were 3＋, the 24h urinary protein was 3.8g, the peak creatinine level was 673.5μmol/L, and renal biopsy revealed 31 intact glomeruli and 23 newly formed crescents, including 11 cellular crescents in patient 1. One month after the patient was treated with penicillin, low dose corticosteroid and hemodialysis, his renal function was still abnormal. Three days after he was treated with intravenous methylprednisolone, 0.5g per day for 3 consecutive days, his renal function returned to normal. The patient was followed up for 2 years, during which his creatinine level and urinary protein decreased to 68μmol/L and 1＋, and occult blood became negative. Laboratory test showed that the proteinuria was 1＋, the occult blood was negative, the peak creatinine level was 216.3,umol/L, and renal biopsy revealed 26 intact glomeruli and 14 newly formed crescents in patient 2. After long-term anti-infection treatment and valve replacement, his renal function returned to normal. The patient was followed up for 2 years, during which his creatinine level decreased to 86.6,umol/L and routine urine test was negative. Conclusion Corticosteroid therapy, even boost corticosteroid therapy, is recommended for patients with cellular crescents while anti-infection therapy and valve replacement are recommended for those with fibrous crescents. The prognosis of the 2 patients reported in this study is quite good.