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.

Invited Speakers

Stewart Lecker
Stewart LeckerCase Presenter | Beth Israel Deaconess Medical Center, Boston, MA, USA | No conflict of interest reported
Isaac Stillman
Isaac StillmanNephropathology Discussant | Beth Israel Deaconess Medical Center, Boston, MA, USA | No conflict of interest reported
Michael Germain
Michael GermainNephrology Discussant | Baystate Medical Center, Springfield, MA, USA | No conflict of interest reported

Case

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.

Medications:
None

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.

Kidney Pathology

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

If you would like to be a contributing author for the creation of didactic materials and case summaries, please contact us at [email protected].