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U0 7 - 801

U0 7 - 801. #816332110 Severe nephrotic syndrome with rising creatinine. 64 yo male of Indian descent with nephrotic syndrome, microscopic hematuria, and ARF (sCr 250) PMhx: 1. CAD: CABG 2001. Asx since, N LVEF 2. DM2 dx 2001 “mild” - gliclizide, metformin

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U0 7 - 801

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  1. U07-801 #816332110 • Severe nephrotic syndrome with rising creatinine

  2. 64 yo male of Indian descent with nephrotic syndrome, microscopic hematuria, and ARF (sCr 250) PMhx: 1. CAD: CABG 2001. Asx since, N LVEF 2. DM2 dx 2001 “mild” - gliclizide, metformin FBS: 9.1 (2004), 6.9 (Feb/06) No Chemstrip monitoring x 2yrs HbA1c: 4.4%, 5.8% (last 5 mo) No known microvascular complications 3. Hypertension dx 2001: BB, HCTZ 4. Dyslipidemia – statin 5. GERD No known kidney disease, stones, BPH, UTIs. No personal/FHx of malignancy. Never smoker, no EtOH.

  3. Admitted Jan 8 – 16th to GIM service @ UAH: -4wk history of increasing leg/scrotal/hand edema -Nausea/presyncope  unresponsive  EMS: C/S=1.0 -No constitutional/CTD sx, cardioresp sx, lower urinary sx Meds: ASA 325, HCTZ 25, Metop 50, Lipitor 20, Panto 40 Metformin 500 bid, Gliclizide 80 bid No NSAIDs/OTC, NDKA On exam: 130/82, P:70, 98% on room air. Well. 3+ edema, JVP 4 cm ASA. No rash/synovitis

  4. P/C=1890 24hr: 20.4 g ACR= 751 Labs: Urinalysis: 11-25 RBC, 6-10 WBC, >20 hyaline casts sAlbumin=15, N Ca/Po4, C3/C4,LFTs N. HepA,B,C –ve ANCA –ve, ANA+, dsDNA-ve, antiGBM –ve U/SPEP: nephrotic picture, no M-band Renal u/s: Normal kidney size/echogenicity, no hydro; CXR: N

  5. P/C= 1800 ACR= 751 Held oral hypoglycemics; req’d ~4U insulin/d for euglycemia Diuresed  maintenance Lasix 40 po OD Held ASA x 5 days RENAL BIOPSY: JANUARY 15th

  6. IF • IgG- Moderate to strong coarsely granular capillary loop staining. • IgA-Negative. • IgM- Moderate irregular coarsely granular capillary loop staining.Mild mesangial staining. • C3- Mild to moderate coarsely granular capillary loop staining. • C1q-Negative. • Kappa and lambda- Moderate coarsely granular capillary loop staining. • Fibrinogen- Moderate interstitial staining. • Albumin-Negative.

  7. IgG

  8. IgM

  9. IgM

  10. C3

  11. Kappa

  12. Lambda

  13. Fibrin

  14. DiagnosisRenal Biopsy: • Membranous glomerulopathy, stage 2 with focal segmental glomerulosclerosis lesions, possibly indicating early diabetic nephropathy.

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