- Email: [email protected]
Crescentic Focal Proliferative Glomerulonephritis Secondary to Enterococcal Urinary Tract Infection
NKF 2016 Spring Clinical Meetings Abstracts
Case Report 33
35
BARRIERS ASSOCIATED WITH INITIATION OF CONTINUOUS A RARE FINDING: ATN AND ANCA ASSOCIATED VASCULITIS IN A PATIENT WITH SCLERODERMA. Valerie Barta. Susana RENAL REPLACEMENT THERAPY IN CRITICALLY ILL Hong. Kenar Jhaveri. NSLIJ, Manhasset, NY, USA. PATIENTS: A TERTIARY CARE HOSPITAL EXPERIENCE 2 There are many potential causes of kidney injury in scleroderma Vasanthi Balaraman, Heather Lefkowitz. Newark Beth Israel Medical (SSc). vasculitis 1 The rare coexistence of SSc and ANCA associated Center, NJ. Laith Al-Rabadi, MBBS,1,* Rivka Ayalon, MD, Ramon G. Bonegio, MD, PhD,1 SSc (AAV) presents a diagnostic challenge when evaluating patients 2,y and mortality. 3 4 Acute kidney injury is associated with high morbidity Jennifer E. Ballard, MD, Alan M. Fujii, MD, Joel progressive M. Henderson, MD, PhD, SSc patients with rapidly kidney injury. In addition, CRRT remains an important dialysis modality in hemodynamically 1 1 (AKI) from drug exposures, frequently developJr, acuteMD, kidney injury J.a Salant, and Laurence H. Beck PhD unstable patients with AKI. WeDavid performed performanceMD, improvement adding to the challenge. project addressing the barriers associated with initiation of CRRT for We present a case of a 52years old Hispanic female with SSc well better outcomes. controlled on low dose steroids who presented with anuric AKI There is little information about pregnancy outcomes in patients with active membranous nephropathy (MN), We retrospectively examined the time interval between the CRRT requiring hemodialysis and respiratory failure requiring intubation. Her receptor the The major especially circulating autoantibodies phospholipase A2 was 2R),prior. order placement and those initiationwith of CRRT in 16 patients. Out of 16to M-typebaseline patient received renal function normal (PLA 2 months autoantigen in primary what we believe to zoledronic be the firstacid known case offor successful pregnancy in were 10 days prior osteoporosis. Her serologies patients, CRRT was initiated within 4 MN. hoursWe in 5 present patients (31%), within MN. In thepositive year prior to poly pregnancy, theand patient within PLA for RNA III, pANCA MPO. developed Emergent bedside 2R-associated 4-8 hours a in 39-year-old 5 patients and woman after 8 hours 4 patients. CRRT was not acute tubular necrosis kidney biopsy revealedexcretion, hypoalbuminemia g/dL), and proteinuria (protein 29.2 g/d). (ATN) Kidneylikely bi- secondary initiated inanasarca, 2 patients due to mortality. CRRT (albumin, was delayed1.3-2.2 more than 4 zoledronic acid in the of chronic AAV and moderate andthis the patientto was seropositive forsetting anti-PLA revealed MN 2with staining forThe PLA hours in 9opsy patients out of which patients expired. reason 2R, for 2R autoantibodies. interstitial fibrosis andrituximab tubular atrophy. She of was1 treated with pulse did not respond to conservative and was treated with intravenous (2 doses g each). delay wereShe cardiac events in 2 patients, difficulty in therapy dialysis catheter steroids and rituximab. She developed diffuse mucocutaneous fungal placement Several in 2 patients, prioritizing other radiological investigations weeks after presentation, she was found to be 6 weeks pregnant and was closely followed up without rash, septic shock and ultimately died of multi organ failure. over CRRTfurther in 1 patient and lack of ICU bedstreatment. in 4 patients.Proteinuria remained AAV immunosuppressive with in protein the to only 12-g/d range. SSc is excretion a rare entity.inAs of 82010 61 cases had been Studies Circulating have supported delay in of CRRT but may were portend levels declined still detectable. At 38 weeks, healthy babyingirl was born, anti-PLA described. In the largestaseries published 2013, only 8 of 2200 SSc 2Rinitiation poorer prognosis. our 408 bedded inneror city early ICU bed patients had coexistent AAV. was more with limited withoutInproteinuria at birth athospital, her subsequent 6-month postnatal visit. At the time ofThis delivery, the associated mother still assignmenthad for detectable patients who need CRRT remains Rchallenging. To cutaneous and and anti-MPO as was seen in our of immunoglobulin G1 (IgG1),SSc IgG3, IgG4positivity, subclasses, although at case. circulating anti-PLA 2 improve outcome, we emphasized the staff on importance of R wereU3RNP also be associatedreasons with overlapping foundantibody in cordmay blood. Potential for the disease. low titers. Only tracetoamounts of the IgG4 anti-PLA 2 Zoledronic acid induced ATN, is also rare especially in patients early initiation of CRRT in face to face education sessions and a policy discrepancy between anti-PLA2R levels in the maternal and fetal circulation are discussed. without oncological diseases. Occurrence of both AAV and was implemented to escalate ICU bed availability when there is delay Am J Kidney Dis. 67(5):775-778. ª 2016 by the National Kidney Foundation, bisphosphonate inducedInc. ATN in a SSc patient has not been previously of more than 4 hours in initiation of CRRT. We introduced SLED as an described. alternative option for patients who are not in ICU and unable to be INDEX WORDS: Membranous nephropathy (MN); nephrotic AAV syndrome; M-type A2 treatment is a rarepregnancy; but serious finding in phospholipase SSc patients. Timely started on CRRT due to lack of immediate bed availability. A recent with immunosuppression is effective, but factors such as concomitant receptor (PLA2R); autoantibody; placenta; rituximab; immunoglobulin G (Ig G) subclass. meta analysis showed extended daily dialysis is associated with similar zolendronic acid induced ATN and infection can complicate diagnosis outcomes to CRRT. Our post intervention follow up data on 10 patients and therapy, potentially leading to death. It is important to recognize showed early CRRT initiation within 4 hours from the time of order the rare possibility of AAV as a cause of AKI in SSc, with early biopsy placement in 9 patients (90% compared to 31% before intervention). and treatment being essential in improving outcomes.
Pregnancy in a Patient With Primary Membranous Nephropathy and Circulating Anti-PLA R Antibodies: A Case Report
P
regnant patients with autoimmune disease may deliver newborns with a spectrum of clinical manifestations due to the transplacental passage of 34 circulating autoantibodies. Pregnant patients with SLEEP DISTURBANCES IN HEMODIALYSIS PATIENTS: Manasi lupus or myasthenia gravisKhan, can Shlomo deliver babiesWinston with Bapat, Priscilla Persaud, Tazleem Greenberg, 1,2 Lee, KC Janga, Sheldon Greenberg, MedicalNeonatal Center, corresponding disease in theMaimonides neonate. Brooklyn, NY,nephropathy USA membranous (MN) not associated with Sleep disturbances are a common complaint amongst hemodialysis congenital infection was first described in 1990 and patients. This leads to an adverse effect in their quality of life. The attributed to the passive transfer purpose of this study is to identify risk factorsof for maternal these sleep anti3 disturbances and to recognize which current therapies are a successful bodies to putative renal antigens. More than decadein thisDebiec patient population. later, et al4 identified the first antigen involved Hemodialysis patients were interviewed from four different dialysis in centers such incases asNY. neutral endopeptidase (NEP), Brooklyn, A questionnaire was used to assess their a metalloprotease present on the surface of the podocyte sleeping habits, risk factors associated with poor sleep, medications and their success, non-pharmacologic therapyof (NPT). andused involved in the and proteolytic regulation vasoacWe obtained 378 complete survey responses. Thirty-eight percent of tivepatients peptides. Debiec et al described a mother with a wake up before 5am. Thirty-three percent of patients complain mutation preventing NEP expression who had formed of difficulty in initiating their sleep requiring >60 minutes. Over 32% of patientsantibodies wake up 3-4 times Thirty-seven percent of anti-NEP duepertonight. fetomaternal alloimmupatientsfrom sleep 1-2 hours per day. About 20% of these patientsantibodies said that their nization a previous miscarriage; quality of sleep was very bad. Poor sleep affected patients’ quality of were to cross the placenta and cause subepithelial life about 50% of the time. There was a statistical correlation between a deposits inofthe kidney of toafallsubsequent pregperception poor fetal sleep with time taken asleep, and number of awakenings. Therephospholipase was no correlation between quality of (PLA sleep and the nancy. M-type A2 receptor 2R) of day of dialysis. Twenty-one percent of patients tookfor priwastime later identified as the major autoantigen medications for sleep on a5routine basis. Eighty-eight percent of mary MN intried adults. Little about patients never NPT while 60.4% literature were willing toexists try. pregnancy outcomes in patients with nephrotic synIn conclusion, sleep disturbances are very common and disabling in the dialysis adversely life. There is drome due population, to primary MN,affecting with their no quality data ofavailable a limited response to medical therapy and under-utilization of NPT about pregnancy in PLA R-associated disease. We despite a large patient interest. 2 present what we believe to be the first known case of pregnancy in a patient with PLA2R-associated MN who was seropositive for anti-PLA2R autoantibodies throughout the course of her pregnancy. Am J Kidney Dis. 2016;67(5):A1-A118
CASE REPORT
A 39-year-old multiparous woman with morbid obesity presented for workup of severe nephrotic syndrome several months 36
before her current pregnancy. She had been treated for resistant CRESCENTIC FOCAL PROLIFERATIVE hypertension and lower-extremity edema during the past year, GLOMERULONEPHRITIS SECONDARY TO butENTEROCOCCAL her proteinuria had been overlooked. At presentation, serum URINARY TRACT INFECTION creatinine level wasKhalillullah, 1.52 mg/dL (corresponding to estimated Allan Bates, Sayeed Xochiquetzal Geiger, Nabeel Aslam. Mayo Clinic Florida, rate Jacksonville, FL, USA glomerular filtration of 46 mL/min/1.73 m2 as calculated by to one third of patients bacterial endocarditis develop acute the Up isotope-dilution masswith spectrometry –traceable 4-variable kidney injury. The most of common are Study staph aureus, MDRD [Modification Diet organisms in Renalinvolved Disease] equastrep viridans, and staph epidermidis. Enterococcal infection has rarely tion); serum albumin level, 1.5 g/dL; and 24-hour urine protein been described as a causative factor in crescentic glomerulonephritis. excretion, 29.2 g. year Theold kidney biopsy specimen revealed features We describe a 68 male with crescentic glomerulonephritis typical ofa primary MNof with additional strong staining for the (GN) as complication enterococcal urinary tract infection. PLAA2R within immune (Fig sweats S1). Many of the 68 antigen year old male presented withdeposits fatigue, night and was being treated as an outpatient presumed UTI.surrounded On exam, temp subepithelial deposits werefor completely by 38.2, new BP 146/76mmHg, HR 76/min. systolicS2), ejection the the basement membrane material3/6 (Fig andmurmur 35% at of
mitral area. No rash or edema. Labs showed WBC 17.8K. S. Cr 0.8 mg/dL. UA Protein 2+, large blood and leukocyte esterase, 29 wbcs/hpf, 182 rbcs/hpf, and granular casts. Blood and urine cultures From the 1Department of Medicine,fecalis. RenalTEE Section, and Dedemonstrated pan-sensitive enterococcus demonstrated a 2 3 4 partments of vegetation. ObstetricsThe and Gynecology, Pediatrics, mitral valve patient was started on ampicillin and and Pagentamicin underwent mitral valve replacement. The patient did thology andand Laboratory Medicine, Boston University Medical well over two weeks Center, Boston, MA. but subsequently developed an acute kidney injury * with S. Cr of 2.8mg/dL. . Random Pr/Cr of 2.6. C3 decreased, ANCA Current affiliation: Department of Internal Medicine, Division negative. Renal biopsy revealed necrotizing crescentic focal of proliferative Nephrology, University of Utah of and Medicine, Salt Lake glomerulonephritis with School mesangial focal loop staining City, withUT. C3 and IgM on IF. The glomeruli had an exudative proliferative y Current affiliation: Department Obstetrics and Gynecology, appearance with intraloop neutrophilsof and fibrinoid necrosis. He requiredWashington two months of dialysis and developed residual stage Medstar Hospital Center, Washington, DC. IV CKD.
Received June 29, 2015. Accepted in revised form October 27, 2015. Originally published online December 29, 2015. Address correspondence to Laurence H. Beck Jr, MD, PhD, Renal Section, X-504, 650 Albany St, Boston, MA 02118. E-mail: [email protected] We describe the second case of enterococcal endocarditis resulting in � 2016 by National Kidney Foundation, Inc. crescentic GN.the Clinicians should be aware of the association of enterococcal 0272-6386 infection leading to glomerulonephritis. http://dx.doi.org/10.1053/j.ajkd.2015.10.031 775 A27
Case Report 33
35
BARRIERS ASSOCIATED WITH INITIATION OF CONTINUOUS A RARE FINDING: ATN AND ANCA ASSOCIATED VASCULITIS IN A PATIENT WITH SCLERODERMA. Valerie Barta. Susana RENAL REPLACEMENT THERAPY IN CRITICALLY ILL Hong. Kenar Jhaveri. NSLIJ, Manhasset, NY, USA. PATIENTS: A TERTIARY CARE HOSPITAL EXPERIENCE 2 There are many potential causes of kidney injury in scleroderma Vasanthi Balaraman, Heather Lefkowitz. Newark Beth Israel Medical (SSc). vasculitis 1 The rare coexistence of SSc and ANCA associated Center, NJ. Laith Al-Rabadi, MBBS,1,* Rivka Ayalon, MD, Ramon G. Bonegio, MD, PhD,1 SSc (AAV) presents a diagnostic challenge when evaluating patients 2,y and mortality. 3 4 Acute kidney injury is associated with high morbidity Jennifer E. Ballard, MD, Alan M. Fujii, MD, Joel progressive M. Henderson, MD, PhD, SSc patients with rapidly kidney injury. In addition, CRRT remains an important dialysis modality in hemodynamically 1 1 (AKI) from drug exposures, frequently developJr, acuteMD, kidney injury J.a Salant, and Laurence H. Beck PhD unstable patients with AKI. WeDavid performed performanceMD, improvement adding to the challenge. project addressing the barriers associated with initiation of CRRT for We present a case of a 52years old Hispanic female with SSc well better outcomes. controlled on low dose steroids who presented with anuric AKI There is little information about pregnancy outcomes in patients with active membranous nephropathy (MN), We retrospectively examined the time interval between the CRRT requiring hemodialysis and respiratory failure requiring intubation. Her receptor the The major especially circulating autoantibodies phospholipase A2 was 2R),prior. order placement and those initiationwith of CRRT in 16 patients. Out of 16to M-typebaseline patient received renal function normal (PLA 2 months autoantigen in primary what we believe to zoledronic be the firstacid known case offor successful pregnancy in were 10 days prior osteoporosis. Her serologies patients, CRRT was initiated within 4 MN. hoursWe in 5 present patients (31%), within MN. In thepositive year prior to poly pregnancy, theand patient within PLA for RNA III, pANCA MPO. developed Emergent bedside 2R-associated 4-8 hours a in 39-year-old 5 patients and woman after 8 hours 4 patients. CRRT was not acute tubular necrosis kidney biopsy revealedexcretion, hypoalbuminemia g/dL), and proteinuria (protein 29.2 g/d). (ATN) Kidneylikely bi- secondary initiated inanasarca, 2 patients due to mortality. CRRT (albumin, was delayed1.3-2.2 more than 4 zoledronic acid in the of chronic AAV and moderate andthis the patientto was seropositive forsetting anti-PLA revealed MN 2with staining forThe PLA hours in 9opsy patients out of which patients expired. reason 2R, for 2R autoantibodies. interstitial fibrosis andrituximab tubular atrophy. She of was1 treated with pulse did not respond to conservative and was treated with intravenous (2 doses g each). delay wereShe cardiac events in 2 patients, difficulty in therapy dialysis catheter steroids and rituximab. She developed diffuse mucocutaneous fungal placement Several in 2 patients, prioritizing other radiological investigations weeks after presentation, she was found to be 6 weeks pregnant and was closely followed up without rash, septic shock and ultimately died of multi organ failure. over CRRTfurther in 1 patient and lack of ICU bedstreatment. in 4 patients.Proteinuria remained AAV immunosuppressive with in protein the to only 12-g/d range. SSc is excretion a rare entity.inAs of 82010 61 cases had been Studies Circulating have supported delay in of CRRT but may were portend levels declined still detectable. At 38 weeks, healthy babyingirl was born, anti-PLA described. In the largestaseries published 2013, only 8 of 2200 SSc 2Rinitiation poorer prognosis. our 408 bedded inneror city early ICU bed patients had coexistent AAV. was more with limited withoutInproteinuria at birth athospital, her subsequent 6-month postnatal visit. At the time ofThis delivery, the associated mother still assignmenthad for detectable patients who need CRRT remains Rchallenging. To cutaneous and and anti-MPO as was seen in our of immunoglobulin G1 (IgG1),SSc IgG3, IgG4positivity, subclasses, although at case. circulating anti-PLA 2 improve outcome, we emphasized the staff on importance of R wereU3RNP also be associatedreasons with overlapping foundantibody in cordmay blood. Potential for the disease. low titers. Only tracetoamounts of the IgG4 anti-PLA 2 Zoledronic acid induced ATN, is also rare especially in patients early initiation of CRRT in face to face education sessions and a policy discrepancy between anti-PLA2R levels in the maternal and fetal circulation are discussed. without oncological diseases. Occurrence of both AAV and was implemented to escalate ICU bed availability when there is delay Am J Kidney Dis. 67(5):775-778. ª 2016 by the National Kidney Foundation, bisphosphonate inducedInc. ATN in a SSc patient has not been previously of more than 4 hours in initiation of CRRT. We introduced SLED as an described. alternative option for patients who are not in ICU and unable to be INDEX WORDS: Membranous nephropathy (MN); nephrotic AAV syndrome; M-type A2 treatment is a rarepregnancy; but serious finding in phospholipase SSc patients. Timely started on CRRT due to lack of immediate bed availability. A recent with immunosuppression is effective, but factors such as concomitant receptor (PLA2R); autoantibody; placenta; rituximab; immunoglobulin G (Ig G) subclass. meta analysis showed extended daily dialysis is associated with similar zolendronic acid induced ATN and infection can complicate diagnosis outcomes to CRRT. Our post intervention follow up data on 10 patients and therapy, potentially leading to death. It is important to recognize showed early CRRT initiation within 4 hours from the time of order the rare possibility of AAV as a cause of AKI in SSc, with early biopsy placement in 9 patients (90% compared to 31% before intervention). and treatment being essential in improving outcomes.
Pregnancy in a Patient With Primary Membranous Nephropathy and Circulating Anti-PLA R Antibodies: A Case Report
P
regnant patients with autoimmune disease may deliver newborns with a spectrum of clinical manifestations due to the transplacental passage of 34 circulating autoantibodies. Pregnant patients with SLEEP DISTURBANCES IN HEMODIALYSIS PATIENTS: Manasi lupus or myasthenia gravisKhan, can Shlomo deliver babiesWinston with Bapat, Priscilla Persaud, Tazleem Greenberg, 1,2 Lee, KC Janga, Sheldon Greenberg, MedicalNeonatal Center, corresponding disease in theMaimonides neonate. Brooklyn, NY,nephropathy USA membranous (MN) not associated with Sleep disturbances are a common complaint amongst hemodialysis congenital infection was first described in 1990 and patients. This leads to an adverse effect in their quality of life. The attributed to the passive transfer purpose of this study is to identify risk factorsof for maternal these sleep anti3 disturbances and to recognize which current therapies are a successful bodies to putative renal antigens. More than decadein thisDebiec patient population. later, et al4 identified the first antigen involved Hemodialysis patients were interviewed from four different dialysis in centers such incases asNY. neutral endopeptidase (NEP), Brooklyn, A questionnaire was used to assess their a metalloprotease present on the surface of the podocyte sleeping habits, risk factors associated with poor sleep, medications and their success, non-pharmacologic therapyof (NPT). andused involved in the and proteolytic regulation vasoacWe obtained 378 complete survey responses. Thirty-eight percent of tivepatients peptides. Debiec et al described a mother with a wake up before 5am. Thirty-three percent of patients complain mutation preventing NEP expression who had formed of difficulty in initiating their sleep requiring >60 minutes. Over 32% of patientsantibodies wake up 3-4 times Thirty-seven percent of anti-NEP duepertonight. fetomaternal alloimmupatientsfrom sleep 1-2 hours per day. About 20% of these patientsantibodies said that their nization a previous miscarriage; quality of sleep was very bad. Poor sleep affected patients’ quality of were to cross the placenta and cause subepithelial life about 50% of the time. There was a statistical correlation between a deposits inofthe kidney of toafallsubsequent pregperception poor fetal sleep with time taken asleep, and number of awakenings. Therephospholipase was no correlation between quality of (PLA sleep and the nancy. M-type A2 receptor 2R) of day of dialysis. Twenty-one percent of patients tookfor priwastime later identified as the major autoantigen medications for sleep on a5routine basis. Eighty-eight percent of mary MN intried adults. Little about patients never NPT while 60.4% literature were willing toexists try. pregnancy outcomes in patients with nephrotic synIn conclusion, sleep disturbances are very common and disabling in the dialysis adversely life. There is drome due population, to primary MN,affecting with their no quality data ofavailable a limited response to medical therapy and under-utilization of NPT about pregnancy in PLA R-associated disease. We despite a large patient interest. 2 present what we believe to be the first known case of pregnancy in a patient with PLA2R-associated MN who was seropositive for anti-PLA2R autoantibodies throughout the course of her pregnancy. Am J Kidney Dis. 2016;67(5):A1-A118
CASE REPORT
A 39-year-old multiparous woman with morbid obesity presented for workup of severe nephrotic syndrome several months 36
before her current pregnancy. She had been treated for resistant CRESCENTIC FOCAL PROLIFERATIVE hypertension and lower-extremity edema during the past year, GLOMERULONEPHRITIS SECONDARY TO butENTEROCOCCAL her proteinuria had been overlooked. At presentation, serum URINARY TRACT INFECTION creatinine level wasKhalillullah, 1.52 mg/dL (corresponding to estimated Allan Bates, Sayeed Xochiquetzal Geiger, Nabeel Aslam. Mayo Clinic Florida, rate Jacksonville, FL, USA glomerular filtration of 46 mL/min/1.73 m2 as calculated by to one third of patients bacterial endocarditis develop acute the Up isotope-dilution masswith spectrometry –traceable 4-variable kidney injury. The most of common are Study staph aureus, MDRD [Modification Diet organisms in Renalinvolved Disease] equastrep viridans, and staph epidermidis. Enterococcal infection has rarely tion); serum albumin level, 1.5 g/dL; and 24-hour urine protein been described as a causative factor in crescentic glomerulonephritis. excretion, 29.2 g. year Theold kidney biopsy specimen revealed features We describe a 68 male with crescentic glomerulonephritis typical ofa primary MNof with additional strong staining for the (GN) as complication enterococcal urinary tract infection. PLAA2R within immune (Fig sweats S1). Many of the 68 antigen year old male presented withdeposits fatigue, night and was being treated as an outpatient presumed UTI.surrounded On exam, temp subepithelial deposits werefor completely by 38.2, new BP 146/76mmHg, HR 76/min. systolicS2), ejection the the basement membrane material3/6 (Fig andmurmur 35% at of
mitral area. No rash or edema. Labs showed WBC 17.8K. S. Cr 0.8 mg/dL. UA Protein 2+, large blood and leukocyte esterase, 29 wbcs/hpf, 182 rbcs/hpf, and granular casts. Blood and urine cultures From the 1Department of Medicine,fecalis. RenalTEE Section, and Dedemonstrated pan-sensitive enterococcus demonstrated a 2 3 4 partments of vegetation. ObstetricsThe and Gynecology, Pediatrics, mitral valve patient was started on ampicillin and and Pagentamicin underwent mitral valve replacement. The patient did thology andand Laboratory Medicine, Boston University Medical well over two weeks Center, Boston, MA. but subsequently developed an acute kidney injury * with S. Cr of 2.8mg/dL. . Random Pr/Cr of 2.6. C3 decreased, ANCA Current affiliation: Department of Internal Medicine, Division negative. Renal biopsy revealed necrotizing crescentic focal of proliferative Nephrology, University of Utah of and Medicine, Salt Lake glomerulonephritis with School mesangial focal loop staining City, withUT. C3 and IgM on IF. The glomeruli had an exudative proliferative y Current affiliation: Department Obstetrics and Gynecology, appearance with intraloop neutrophilsof and fibrinoid necrosis. He requiredWashington two months of dialysis and developed residual stage Medstar Hospital Center, Washington, DC. IV CKD.
Received June 29, 2015. Accepted in revised form October 27, 2015. Originally published online December 29, 2015. Address correspondence to Laurence H. Beck Jr, MD, PhD, Renal Section, X-504, 650 Albany St, Boston, MA 02118. E-mail: [email protected] We describe the second case of enterococcal endocarditis resulting in � 2016 by National Kidney Foundation, Inc. crescentic GN.the Clinicians should be aware of the association of enterococcal 0272-6386 infection leading to glomerulonephritis. http://dx.doi.org/10.1053/j.ajkd.2015.10.031 775 A27