Mcbride S1, Jeffs L1, Jose M1,2
1Royal Hobart Hospital, Hobart, Australia, 2University of Tasmania, Hobart, Australia
Background: Cardiorenal Syndrome (CRS) describes the bi-directional relationship between cardiac and renal dysfunction. Type 3 CRS describes cases where acute kidney injury (AKI) causes acute cardiac dysfunction.
Case Report: We report 2 patients presenting with acute left ventricular (LV) failure following diagnosis of Myeloperoxidase (MPO) antineutrophil cytoplasmic autoantibody (ANCA) associated glomerulonephritis (GN).
A 73-year-old man presented with AKI (Creatinine 677 ummol/L) and positive MPO-ANCA (187.0 IU/mL, [<6.0] ). Kidney biopsy showed pauci-immune vasculitis and crescentic GN. He was treated with intravenous (IV) methylprednisolone, cyclophosphamide and haemodialysis. Trans-thoracic echocardiogram (TTE) demonstrated LV ejection fraction (LVEF) 45%. His weight on discharge was 65.8kg. He represented 7 days later with acute pulmonary oedema (APO) and a weight of 70.2kg. Repeat TTE showed new severe global systolic dysfunction (LVEF 15-20%). Troponin was elevated (172 ng/L [<15] ). Treatment with aggressive ultrafiltration achieved 12.7kg fluid removal (18% body weight). Coronary angiogram and cardiac PET showed no significant disease. Follow-up TTE at 4 months showed LVEF 50%.
A 25-year-old female presented with AKI (Cr 1900) and positive MPO-ANCA (129.9). Kidney biopsy demonstrated global glomerulosclerosis, with tubulointerstital nephritis and evidence of thrombotic microangiopathy. She was treated with IV methylprednisolone, plasmapheresis, rituximab and haemodialysis. TTE showed LVEF 50%. Her weight on discharge was 72kg. She represented 11 days later with APO and a weight of 67kg. Repeat TTE showed new severe global systolic dysfunction (LVEF ~15%). Troponin was raised (190). Treatment with ultrafiltration removed 11.5kg (17% body weight). Follow-up TTE at 3 months showed LVEF 35-40%.
Conclusions: These cases demonstrate type 3 CRS in patients with denovo MPO-ANCA associated GN. Effective acute treatment required aggressive ultrafiltration with removal of >15% body weight.
Sarah is a first year renal registrar and nephrology advanced trainee at the Royal Hobart Hospital. She completed her basic physician training at Monash Health, Melbourne. Outside of hospital she enjoys swimming, piano and playing Dungeons and Dragons. She is a proud mother of 7 indoor plants.