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
Helmut Rennke
Helmut RennkeNephropathology Discussant | Brigham and Women's Hospital, Boston, MA, USA | No conflict of interest reported
Johannes Schlondorff
Johannes Schlondorff Nephrology Discussant | Beth Israel Deaconess Medical Center, Boston, MA, USA | Conflict of interest reported: Partners Healthcare/BWH – Patent/IP

Case

Patient is a 20-year-old female with a history of lupus nephritis who developed worsening proteinuria during a 2-week hospital admission.

Lupus nephritis history: class IV lupus nephritis on biopsy ~10 years prior to presentation, treated with mycophenolate and prednisone with good response. Now in remission on maintenance mycophenolate/prednisone, baseline creatinine ~0.5, urinalysis dip-negative as recently as 4 weeks ago.

She was admitted to the hospital for abdominal pain ~2 weeks ago, felt to be lupus enteritis. Low-grade proteinuria was seen on admission (1 g/24 hour). She was given pulse steroids followed by 1 mg/kg PO.

Two doses of IV ketorolac were given early in her course for the pain. Her course was complicated by pneumonia, then infected bilateral pleural effusions. In that setting, mycophenolate was held. Approximately 10 days later, with slow overall improvement, her urine was re-examined because of weight gain and edema.

The 24hr collection showed 26 gram of protein.

Medications:

Medications at time of current evaluation: prednisone 60 mg daily, hydroxychloroquine, cefepime, omeprazole

Physical Exam:
Blood pressure 105/50, HR: 95, RR 15.
10kg weight gain over 2 weeks. Cachectic. Anasarca.

Laboratory and other data:
White blood and red blood cell count normal, BUN 30 mg/dl, creatinine 0.5 mg/dl, albumin 1.5 g/dl, cholesterol 102 mg/dl
Urinalysis: 4+ protein, trace blood, sediment: 1-3 RBCs/hpf, occasional coarse granular casts

Kidney Pathology

Pathology images pending

Preliminary report: mesangial lupus (class II), not active. Minimal Change Disease.

Questions posed & summary of key discussion points

1. What are the differential diagnoses and treatment options to consider?

Author(s) of case summary:

Case summary pending

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