**4. Septic embolism to the kidneys**

Despite numerous case reports, available clinical data on SE to the kidneys continue to be limited [2, 69–71]. Embolic events associated with IE involve kidneys in 6–14% cases (**Fig‐ ure 1**) and exhibit highly variable pattern of presentation [2, 69]. Most patients complain of an acute onset of abdominal, flank, or back pain. The pain is typically constant. Approximately half of reported cases present with fever and vomiting. Acute secondary hypertension from renin release due to decreased arterial perfusion may be seen. Laboratory findings may include leukocytosis, proteinuria, hematuria, elevated levels of lactate dehydrogenase, serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, and alkaline phosphatase [70]. Potential complications of septic emboli include hematuria, glomerulonephritis, or infarction leading to loss of renal function. Three types of severe renal manifestations may be seen: renal infarcts, focal "embolic" glomerulonephritis, and acute diffuse glomerulonephritis [72]. Renal loss due to embolic occlusion of the renal artery has been reported [71]. Of interest, localized renal infarcts were found in over 30% of necropsy samples, with more than half attributable to SE in patients infected with *Staphylococcus aureus* [69]. Renal SE and infarction may be associated with concurrent embolic events to other organs (**Figure 4**) [73]. In one reported case, renal infarction was found in conjunction with SE to the coronary arteries and the spleen [74]. In another case, multiple acute SE infarcts due to Gram-positive aortic valve IE were found in the brain, spleen, kidneys, and the intestine [75]. Treatment is usually supportive, consisting of systemic antibiotics, renal replacement therapy (if indicated) [69], and only rarely involves percutaneous or open procedural interventions [14, 76]. Preservation of renal function is the primary goal.

**Figure 4.** The presence of simultaneous renal (A) and splenic (B) infarctions secondary to septic embolism. Source: Modified from Grob et al. [73]. Used under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
