Corticosteroids after Hemodialysis May Improve Kidney Function in Infection-Related Glomerulonephritis

Introduction: Staphylococcus-associated Glomerulonephritis (SAGN) is an uncommon renal phenomenon following staphylococcal bacteremia, where management involves intravenous antibiotics. We report a case of severe, persistent SAGN requiring hemodialysis, with improvement through glucocorticoids, thus, paving a path for the reassessment of guidelines for SAGN after the use of antibiotics. Case Description: A 74-year-old male with a history of end-stage renal disease, kidney transplant and now on tacrolimus, nephrectomy for oncocytoma presented with a right foot digit gangrene and septic shock. Workup was remarkable for a urinalysis consistent with a UTI, and blood cultures showing methicillin-susceptible staphylococcal aureus. His course was further complicated by endocarditis, worsening creatinine from baseline, and volume expansion refractory to diuretics requiring hemodialysis. Following 4 sessions, his creatinine continued to rise. Due to a broad set of differentials including transplant rejection, thrombotic microangiopathy and tacrolimus toxicity, a renal biopsy was performed. At this time, he had a negative ANCA-level and hypocomplementemia with C3, most consistent with IRGN which was later confirmed by biopsy. Given the severity of his AKI requiring HD, a decision was made to treat with a course of 500mg IV methylprednisolone followed by 5mg Prednisone daily, after which his creatinine down-trended and he did not require further dialysis. Discussion: Infection-related glomerulonephritis (IRGN), more specifically SAGN, involves the deposition of preformed immune complexes during, or a few days following concurrent infection. It is presumed that treatment with antibiotics will reduce antigen production, and therefore, decrease kidney inflammation. Previous studies show that treatment with corticosteroids is ill-advised as it poses a risk of recurrent sepsis and increases mortality. Our case highlights three pearls: the uniqueness of a severe acute kidney injury requiring hemodialysis, the importance of a kidney biopsy for an unclear etiology, and the initiation of high-dose corticosteroids in an immunocompromised individual for uncontrolled glomerulonephritis. This case brings to light the need to constantly evaluate the driving process of SAGN, whether it is inflammation or infection, to determine if an immunosuppressive approach should be taken.