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

Jonathan Slater
Jonathan SlaterCase Presenter | Baystate Medical Center, Springfield, MA, USA | No conflict of interest reported
Stewart Lecker
Stewart LeckerNephrology Discussant | Beth Israel Deaconess Medical Center, Boston, MA, USA | No conflict of interest reported

Case

The patient is a 65-year-old female with idiopathic nonalcoholic cirrhosis and longstanding DM, who was seen by Hematology for low platelets of 100.000. At that visit, laboratory data also noted new acute kidney injury with a serum creatinine of 4.5 mg/dl (up from a baseline of ⅙ mg/dl). The patient was admitted to the hospital for workup and evaluation, which was unrevealing.

During the hospital course creatinine decreased to 3.5 mg/dl which was in the setting of discontinuation of lisinopril.

Medical history:
Diabetes mellitus type 2, HTN, metabolic syndrome, idiopathic nonalcoholic liver cirrhosis

Medications:
Nifedipine, atenolol, insulin, liraglutide, metformin

Physical Exam:
Obese, fatigued appearing female, without any rash or other focal findings

Laboratory and other data:
Kidney function as above
Platelets 87 thousand;
All serologies negative (ANCA, ANA, HepB/C, Immunofixation, C3/C4);
LDH/Hapto all normal and no schistocytes

Kidney Pathology

Pathology images pending

Patient underwent 2 kidney biopsies

Kidney Bx #1: 75% of glomeruli sclerotic; 50% chronic interstitial fibrosis involving the cortical area. No IF/EM available.

Kidney Bx #2:  Significant global glomerulosclerosis, interstitial fibrosis, significant interstitial inflammatory changes suggestive of acute and some chronic interstitial nephritis.

IF: Non-sclerotic glomeruli showing 3 plus mesangial staining for IgA

Questions posed & summary of key discussion points

1. What therapeutic approach should be taken given her biopsy results?

Author of case summary: 

Case summary pending

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