u0 7 - 801
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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U07-801
#816332110
• Severe nephrotic syndrome with rising creatinine
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64 yo male of Indian descent with nephrotic syndrome, 64 yo male of Indian descent with nephrotic syndrome, microscopic hematuria, and ARF (sCr 250)microscopic hematuria, and ARF (sCr 250)
PMhx: PMhx: 1. CAD: CABG 2001. Asx since, N LVEF1. CAD: CABG 2001. Asx since, N LVEF2. DM2 dx 2001 “mild” - gliclizide, metformin2. DM2 dx 2001 “mild” - gliclizide, metformin FBS: 9.1 (2004), 6.9 (Feb/06)FBS: 9.1 (2004), 6.9 (Feb/06) No Chemstrip monitoring x 2yrs No Chemstrip monitoring x 2yrs HbA1c: 4.4%, 5.8% (last 5 mo)HbA1c: 4.4%, 5.8% (last 5 mo) No known microvascular complicationsNo known microvascular complications3. Hypertension dx 2001: BB, HCTZ3. Hypertension dx 2001: BB, HCTZ4. Dyslipidemia – statin4. Dyslipidemia – statin5. GERD5. GERD
No known kidney disease, stones, BPH, UTIs.No known kidney disease, stones, BPH, UTIs.No personal/FHx of malignancy. Never smoker, no EtOH. No personal/FHx of malignancy. Never smoker, no EtOH.
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Admitted Jan 8 – 16Admitted Jan 8 – 16thth to GIM service @ UAH: to GIM service @ UAH:
-4wk history of increasing leg/scrotal/hand edema-4wk history of increasing leg/scrotal/hand edema
-Nausea/presyncope -Nausea/presyncope unresponsive unresponsive EMS: C/S=1.0 EMS: C/S=1.0
-No constitutional/CTD sx, cardioresp sx, lower urinary sx-No constitutional/CTD sx, cardioresp sx, lower urinary sx
MedsMeds: ASA 325, HCTZ 25, Metop 50, Lipitor 20, Panto 40: ASA 325, HCTZ 25, Metop 50, Lipitor 20, Panto 40
Metformin 500 bid, Gliclizide 80 bidMetformin 500 bid, Gliclizide 80 bid
No NSAIDs/OTC, NDKANo NSAIDs/OTC, NDKA
On examOn exam: 130/82, P:70, 98% on room air. Well.: 130/82, P:70, 98% on room air. Well.
3+ edema, JVP 4 cm ASA. No rash/synovitis3+ edema, JVP 4 cm ASA. No rash/synovitis
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ACR=751
P/C=189024hr: 20.4 g
LabsLabs: Urinalysis: 11-25 RBC, 6-10 WBC, >20 hyaline casts: Urinalysis: 11-25 RBC, 6-10 WBC, >20 hyaline casts sAlbumin=15, N Ca/Po4, C3/C4,LFTs N. HepA,B,C –vesAlbumin=15, N Ca/Po4, C3/C4,LFTs N. HepA,B,C –ve ANCA –ve, ANA+, dsDNA-ve, antiGBM –veANCA –ve, ANA+, dsDNA-ve, antiGBM –ve U/SPEP: nephrotic picture, no M-bandU/SPEP: nephrotic picture, no M-bandRenal u/sRenal u/s: Normal kidney size/echogenicity, no hydro; : Normal kidney size/echogenicity, no hydro; CXRCXR: N: N
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ACR=751
P/C=1800
Held oral hypoglycemics; req’d ~4U insulin/d for euglycemiaHeld oral hypoglycemics; req’d ~4U insulin/d for euglycemia
Diuresed Diuresed maintenance Lasix 40 po OD maintenance Lasix 40 po OD
Held ASA x 5 daysHeld ASA x 5 days
RENAL BIOPSY: JANUARY 15RENAL BIOPSY: JANUARY 15thth
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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.
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IgG
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IgM
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IgM
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C3
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Kappa
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Lambda
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Fibrin
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DiagnosisRenal Biopsy:• Membranous glomerulopathy, stage 2 with
focal segmental glomerulosclerosis lesions, possibly indicating early diabetic nephropathy.