Acute renal failure after bacteraemia and endocarditis.

A 68-year-old woman, with a history of arterial hypertension, atrial fibrillation, and chronic liver disease due to HCV was hospitalized for bacteraemia and mechanical prosthetic mitral valve endocarditis associated with methicillinsensitive Staphylococcus aureus. She received antimicrobial therapy (cloxacillin, 6 guday and rifampicin 300 mguday for 6 weeks; gentamicin, 1 mgukguday for 2 weeks). Subsequently, the patient developed oligoanuric acute renal failure (ARF) (creatinine 4.2 mgudl; proteinuria -1 guday and microscopic haematuria), associated with reduced C3 and C4 plasma levels (C3, 35.5 mgudl; C4, 15 mgudl). After 7 days of continuous venovenous haemofiltration therapy and intermittent haemodialysis for an additional 20 days, renal function returned almost to the previous baseline (creatinine 1.3 mgudl; Ccr 30 mlumin); in addition, plasma C3 and C4 levels were normal (C3, 99.5 mgudl; C4, 31.5 mgudl). Abdominal ultrasound revealed a normal right kidney (12 cm) with good corticomedullar, differentiation and no sign of any obstructive process; the left kidney (7–8 cm) showed many cortical scars. Haemocultures were sterile and there were no echocardiographic signs of endocarditis. After admission, the use of a urinary catheter was necessary for diuresis measurement, and persistent candiduria was noted (urine culture was positive for Candida albicans). After 2 weeks, a rapid rise in serum creatinine (3 mgudl) together with a fall in diuresis volume, fever, and flank pain were evaluated by unenhanced computerized tomography of the abdomen. Dilatation of the right collecting system and poor visualization of the left kidney were noted. In this setting, a right percutaneus nephrostomy was performed and a purulent fluid was drained. Candida albicans and Candida glabrata were found in fungal cultures of this renal pelvic urine. An anterograde pyelogram demonstrated a radiolucent filling defect in the right renal pelvis (Figure 1).