#726 The ugly face of shunt nephritis

Abstract

Abstract Background and Aims Shunt nephritis is a rare immune complex-mediated reversible glomerulonephritis due to infected ventricular shunts, most commonly ventriculo-peritoneal shunts (VP) for the treatment of hydrocephalus. Although infection of CSF is common, shunt nephritis is rare, however remains a life-threatening disorder with a high possibility of the development of glomerulonephritis (GN), chronic kidney disease (CKD) & death. Antibiotic treatment alone is generally ineffective in resolution of GN, but removal of the shunt is usually, associated with improvement of the renal disease. Method We have reported four cases with shunt-nephritis that had occurred in consequence of infected VP shunt for treatment of hydrocephalus. The clinical courses, immunological, and histological findings were different in the reported cases, however the same management by removal of the shunt system led to an improvement of the laboratory parameters & clinical symptoms in 3 patients. Results The 1st case was a 10 -year-old boy who had VP shunt (inserted at the age of 5, for managing post meningoencephalitis hydrocephalus), came with acute kidney injury (AKI) without recent proceeding infection. Renal biopsy revealed picture of membranoproliferative GN (MPGN), however his initial CSF analysis was −ve for infection, however, 4 months later, repeat CSF culture was +ve for Propionibacterium acnes. The patient was admitted for shunt removal & 1 month course of antibiotic. AKI & GN improved with normalization of C3 after 2 months. The 2nd case was 15-year-old girl with VP shunt at age of 9 months due to congenital hydrocephalus, who came with shunt dysfunction, AKI, high fever & hematuria. CSF analysis was +ve for staphylococcus coagulase & staphylococcus aureus, where a 1 month course of antibiotic hadn't improve the symptoms. Renal biopsy showed MPGN. Shunt removal with insertion of new one, was associated with marked improvement of AKI with normalization of complement levels. The 3rd case was a 7-year-old girl who came with picture of sepsis, and convulsions. She had VP shunt inserted since the age of 3 months as a consequence of neonatal sepsis & intracranial hemorrhage. She had AKI & consumed C3. CSF analysis revealed streptococcal pneumonia. Renal biopsy showed diffused proliferative GN with 50% crescentic formation. Patient needed parenteral antibiotic course for 14 days, twice hemodialysis session & pulse steroid without improvement, however shunt removal & insertion of new one was associated with marked improvement of symptoms, and she diagnosed as shunt nephritis. The 4th case was 18-year-old female with came with manifestation of increased intracranial pressure, and fever of 1 month duration. She had VP shunt because of traumatic intraventricular hemorrhage at age of 7. Initial investigations revealed sepsis, AKI & consumed C3. Antibiotic couldn't manage her AKI. Renal biopsy showed MPGN. CSF analysis was +ve for coagulase-negative Staphylococcus. VP shunt was removed & 1 month course of antibiotic was given without improvement of her AKI and she turned into CDK stage 3. Conclusion The importance of regular observation & narrow-interval follow-up investigations for early recognition of this reversible form of glomerulonephritis is emphasized.