Patient is a 70 yrs. old male referred for elevated creatinine and proteinuria. He has had mildly elevated blood pressures which have been systolic in the 140-150 range and 80’s for diastolic but more recently in 165/95 range. He was taken off lisinopril because of hyperkalemia within the past year, with a creatinine of around 1.3-1.4 mg/dl. He denies any history of dysuria, hematuria, urgency, increased frequency, nocturia. He has foamy urine. For the past 2-3 months he has been having swelling in his legs. ROS otherwise negative.
Furosemide daily, isosorbide daily, metoprolol twice daily, simvastatin every night, amlodipine daily.
He denies any NSAID or herbal medication use. He was recently started on isosorbide.
Right femoral bruit, 3+ edema
Laboratory and other data:
Microscopic examination of the urine reveals possible RBC casts. Dipstick shows 3+ protein and 2+ RBC.
The patient’s last creatinine values prior to this visit were:
Serum creatinine 1.38 mg/dl
Serum creatinine 1.32 mg/dl
Serum creatinine 1.28 mg/dl
Urinary protein/creatinine ratio of 8 g/g
C3 78 low
C4 17 low normal
Hep B and C negative
Rheumatoid Factor: negative
Serum and urine electrophoresis (SPEP and UPEP)): negative for monoclonal proteins.
Ultrasound: Left Kidney 12 cm and Right 11 cm with normal echogenicity.
Short term follow up:
After the biopsy, the patient was started on angiotensin receptor blocker, without noticeable improvement in proteinuria. In fact the kidney function worsened; creatinine increased to 1.5 mg/dl and serum potassium increased to 6.1 mEq/l on two separate occasions. Baseline anemia is worsening.