To preserve patient privacy and for didactic purposes, case descriptions and pathology reports have been anonymized and partially fictionalized. The pathology images are representative images from a mixture of similar cases.
Stewart LeckerCase Presenter | Beth Israel Deaconess Medical Center, Boston, MA, USA | No conflict of interest reported
Isaac StillmanNephropathology Discussant | Beth Israel Deaconess Medical Center, Boston, MA, USA | No conflict of interest reported
Michael GermainNephrology Discussant | Baystate Medical Center, Springfield, MA, USA | No conflict of interest reported
Patient is a 35-year-old man, who initially presented to nephrology clinic for foamy urine noted ~3 months prior to current evaluation. Otherwise he felt well, with perhaps some vague malaise. He had no abdominal cramping or pain, no rashes, no joint complaints or other constitutional symptoms.
Physical Exam: BP 125/85, HR 65, BMI 24. completely normal exam.
Laboratory and other data: BUN 15 mg/dl Creatinine 0.9 mg/dl Normal electrolytes Cholesterol 220 LFTs normal Hepatitis serologies ANA, ANCA all negative. C3 and C4 normal Urine analysis: 1.025, pH6.5, 4+blood, 3+protein. Lipid casts and free fat, numerous acanthocytes, no cellular casts. Urine protein to creatinine ratio 5 g/g
Short term follow up: He was initiated on lisinopril and glucocorticoid therapy with prednisone 1 mg/kg/day. Within a month, he developed labile mood changes. Protein-to-creatinine ratio initially decreased from 5 g/g to 1.5 g/g, then increased back to 4 g/g with the taper Now the patient is seen in nephrology clinic for follow up. He feels great, with absolutely no rheumatological or constitutional symptoms. Current medications: Lisinopril 10 mg daily, prednisone 10 mg daily, Physical exam normal. BP 120/82, BMI 24. UA: 3+ protein, large blood, numerous acanthocytic red blood cells. BUN 29, creatinine 1.5, Urine protein/creatinine ratio 4 g/g.
Pathology images pending
IgA nephropathy with 10-15% crescents.
Questions posed & summary of key discussion points
1. How would you treat patient next given the poor tolerance and poor response to steroids? 2. Would you re-biopsy?
Author(s) of case summary:
Case summary pending
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