U07-801

#816332110

• Severe nephrotic syndrome with rising creatinine

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.

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

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

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

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.

IgG

IgM

IgM

C3

Kappa

Lambda

Fibrin

DiagnosisRenal Biopsy:• Membranous glomerulopathy, stage 2 with

focal segmental glomerulosclerosis lesions, possibly indicating early diabetic nephropathy.