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204060810 U06-5523

204060810 U06-5523. DM with microhematuria. 44 yr married female,mother of two children, referred to the Renal clinic by family physician on january 27,2006 for investigation of protienuria with IDDM H/O Diabetes- Dx 1990-Gestational Age 29 Type 2- 7 years

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204060810 U06-5523

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  1. 204060810 U06-5523 DM with microhematuria

  2. 44 yr married female,mother of two children, • referred to the Renal clinic by family physician on january 27,2006 for investigation of protienuria with IDDM • H/O Diabetes- Dx 1990-Gestational Age 29 • Type 2- 7 years • IDDM—4 years • Having laser treatment for retinopathy-partial blindness Left eye—2 years • Patient has no urinary symptoms • Depressed-recent death of her mother • Presenting features: • Hypertension-143/83 on Rx with ARB/HCTZ • Poorly controlled diabetes- HbAIc 9% • Urine analysis-protein,blood and red cell cast • Nephrotic range proteinuria (7gm/24hr) • Serum creatinine-166umol/L • GFR-31ml/min/1.73m2(MDRD) • C3/C4-normal • Quantitive Ig-IgG,IgA and IgM-normal • ANA-negative • U/S abdomen-normal kidneys U06-5523

  3. U06-5523 Other medical conditions: 1.hyperlipidaemia 2.hypothyroidism 3.anemia-normochromic,normocytic 4.Migraine headache Past Health: Diabetes diagnosed with pregnancy age 29-1990:Scr 57umol/L 1997-Scr 70umol/L- no proteinuria 2002-Scr 70umol/L-no proteinuria Renal diagnosis: 1. Chronic Kidney disease-Stage3 2. Nephrotic range of proteinuria + Hematuria ? Diabetic nephropathy with other parenchymal renal disease Plan: Investigate- renal biopsy

  4. IF • IgG-moderate background • IgA- minimal but definite granular mesangial in several segments of the non-sclerotic glomerulus. • IgM- trace mesangial,close to negative • C3- moderate to strong vascular and Bowman’s capsule near the vascular pole,with a few tiny mesangial granules • C1q-negative • Kappa-moderate basement membrane background with a few mesangial granules of doubtful significance • Lambda-same as kappa • Fibrin- moderate interstitial staining • Albumin- moderate to strong basement membrane background

  5. IgA

  6. C3

  7. Kappa

  8. Lambda

  9. Fibrin

  10. Albumin

  11. Comment: As well as the obvious diabetic nephropathy, the IF supports the presence of a small amount of mesangial IgA deposition,and the EM although indeterminate is at least consistent. The picture indicates a component of IgA nephropathy, but the advanced diabetic changes are by far the predominant process here.

  12. Diagnosis:Renal Biopsy:Advanced Diabetic Nephropathy. Superimposed focal proliferative Glomerulonephritis on the basis of IgA Nephropathy.

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