Patient is a 39-year-old female with a history of nephrotic syndrome who wishes to become pregnant and is planning IVF. Several years ago, she developed nephrotic syndrome with anasarca, serum albumin of 1.8 g/dl, nephrotic range proteinuria, and serum creatinine level of 0.6 mg/dl.

She had a kidney biopsy at the time of initial presentation many years ago: none of the glomeruli were sclerotic, there was diffuse foot process effacement. The diagnosis was consistent with minimal change.

She was treated with prednisone 60 mg/day, but she did not have a good response to therapy.

Few months after steroid initiation, her serum albumin declined further to 1.7 g/dl with a urine protein/Cr ratio of >10; creatinine was 0.7 mg/dl.

Approximately 6 months later, she presented with anasarca (~20 kg weight gain) and pulmonary edema. She had a complicated one-month hospital admission, where she was treated with diuretics and glucocorticoids but her serum albumin remained low at 1.7 and serum creatinine now was elevated at 1.8 mg/dl. Her admission was complicated by infection and other severe steroid side effects.

A few months later she was rehospitalized.

Labs on admission included: Serum albumin 1.5 mg/dl, creatinine 2.2 mg/dl, urine protein 8 grams/day; She was diagnosed with steroid-induced diabetes, and on the exam with anasarca, including massive ascites. She was given prednisolone but this was gradually tapered and cyclosporine was started.

She was also treated with losartan, spironolactone, atorvastatin, and warfarin. She also underwent LDL apheresis. At this point the presumed diagnosis was FSGS.

She took different doses of prednisolone and cyclosporine over the years. ARB and warfarin were stopped 2 years later.

More recently she has been off all medications.

She feels well.

She continues to check her urine by dipstick at home and has had little or no proteinuria recently.

Medical history:
Steroid induced diabetes
Bacteremia
Obesity

Medications:
Prenatal vitamins
Occasional acetaminophen

Physical Exam:
Currently BP 130/82. Exam essentially normal. No edema.

Laboratory and other data:
Normal white and red blood cell count, normal electrolytes
Creatinine 0.7 mg/dl
Total cholesterol 181 mg/dl
Serum albumin 4.1 g/dl
C3: 80 mg/dL (normal 90-160); C4 20 mg/dL (normal 14-30)
Urine protein to creatinine ratio 0.5 g/g