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U06-12318 #605635810. 71 yo male,ARF (cr ~300) RBC casts ++ %g/day proteinuria PANCA +ve. U06-12318. 70 yo M admitted to CTU medicine (June 13) with confusion, ARF (sCr 285), anorexia, wt loss, weakness PMhx : Htn, dyslipidemia, COPD (80 py smoker), DHS R hip ?osteoporosis,

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U06 12318 605635810

U06-12318

#605635810

71 yo male,ARF (cr~300)

RBC casts ++

%g/day proteinuria

PANCA +ve


U06 12318 605635810

U06-12318

70 yo M admitted to CTU medicine (June 13) with confusion,

ARF (sCr 285), anorexia, wt loss, weakness

PMhx:

Htn, dyslipidemia, COPD (80 py smoker), DHS R hip ?osteoporosis,

?Etoh abuse. No documented renal disease.

HPI

2 months ago: Visiting BC: picked up by police for driving erratically:

admitted to hospital with delirium NYD, treated with risperidone:

d/c after 1 week. sCr 170 (May, 2005: sCr=99).

No documentation / discharge history available

June 12: UAH ER: 1 mo history of anorexia, weakness,

poor coordination, tremor, confusion. (Poor historian – separated from wife, few family)

Meds: Risperidone, ASA, Coversyl 4mg OD.

Physical Exam:

183/84, AFib 180  NSR 80 with fluid. Afebrile. Wasted: 47 kg.

Disoriented x 3, agitated, resting tremor. No focal neuro signs.

Clinically dry: dry MM, flat JVP, no edema. PPP. Lungs clear.

No active joints, rashes, lymphadenopathy, bruits.


U06 12318 605635810

Initial Investigations

sCr 287, urea 40.

U/A: 3+ protein, prot/Cr=469 mg/mmol, 26-50 RBC, occ WBC, occ hyaline casts.

Urine C+S: no growth

Na=153, K/TCO2/Cl N. sAlbumin=19, Ca=1.73, Po4=1.63, Mg N. LFTs, NH3, CK N.

CBC: Hb 138 (MCV 95), Plt 159, WBC 6.1. Smear: no schistos, no hyperseg PMNs

 Renal U/S: N sized kidneys, increased echogenicity. No masses/hydro.

Course in Hospital

-Admitted to CTU with confusion ?EtOH withdrawal, ARF, hypovolemia, AFib.

-Supportive care: IV crystalloid, benzos

-sCr: 284 (6/12)  316 (6/13)  315 (6/14)

-Nephro consult (6/15): suspected pre-renal ARF with underlying intrarenal process.

Too combative for biopsy: repeat urine studies and serology

-SPEP/UPEP –ve for M-band, C3 0.73 (N 0.8-2.0), C4 N, anti-GBM negative

-

June 20: pANCA +ve, cANCA –ve, ANA+, dsDNA –ve

Urine microscopy: ++RBC casts and heme-granular casts

Minimal improvement in mental status

CT head: non-acute ischemic lesions L frontal lobe and peri-ventricular white matter

-June 21 (Wednesday): RENAL BIOPSY (after sedation)


U06 12318 605635810

Diagnosis:

Renal Biopsy:

Arteritis with fibrinoid change and medium sized

arteries with consequent tubular damage and

membranoproliferative glomerulonephritis with

occasional crescent formation.


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