Nephrology

  1. A 65 year old woman is seen in clinic for significant swelling in the feet and morning puffiness around her eyes.  This was preceded by a 3 week history of back pain for which she had been using ibuprofen regularly for symptom control. Her only history is significant for osteoporosis for which she is currently on aledronate and vitamin D 2000 IU daily.  The examination revealed a blood pressure of 141/85, heart rate of 89 bpm and the rest of the vitals normal. The physical examination reveals bilateral pitting edema  up to the knees, JVP of 4 cm, clear lungs and normal heart sounds with no extra heart sounds. Investigations including creatinine was 89 µmol/L and urine albumin/creatinine ratio of 5000 μg/mg.

What would be the next steps in the management of this patient?

A. Start lisinopril
B.Stop ibuprofen and arrange for a 24 hour urine collection for protein
C.Start amlodipine
D. Arrange for a renal biopsy


2. A 28-year-old woman is scheduled to undergo a kidney biopsy for diagnostic & prognostic purposes as she has a long-standing history of systemic lupus erythematosus.  She also has a history of poorly controlled hypertension. Her current medications including prednisone, plaquenil, hydrochlorothiazide, bisoprolol, irbesartan, and vitamin D. On examination her blood pressure is 180/89 mm Hg.  Her blood count revealed a hemoglobin of 105, platelet count of 120 × 109/L and creatinine of 135 µmol/L.

Which of the following would be a contraindication to proceeding with the kidney biopsy?

A.  anemia
B. platelet count
C. creatinine level
D. poorly controlled hypertension


3. A 74 year old man is seen in clinic for an increase in his creatinine noted by his general practitioner from 100 to 189 µmol/L. He was recently admitted to hospital where he received IV gentamicin for an enterobacter abscess. His medical history is only significant for hypothyroidism for which he currently takes levothyroxine. His urinalysis only revealed trace proteinuria. On exam his blood pressure is 137/78 mmHg, heart rate of 78 bpm. His JVP was normal and there was no proteinuria. His microscopy showed the following:

Image-1

What is the most likely diagnosis accounting for his acute renal injury?

A. acute interstitial nephritis (AIN)
B. rapidly progressive glomurelonephritis (RPGN)
C.  acute tubular necrosis (ATN)
D. Fanconi’s syndrome


4. A 45 year old woman is seen in clinic for pitting bipedal pitting edema and hypertension with a blood pressure of 151/85 only on amlodipine 10 mg daily. Her creatinine is 78 µmol/L and other electrolytes are normal. She had 24 hour urine collection which showed 2.8 grams of protein. Extensive workup including HIV, Hepatitis, lupus and medication review was unremarkable. She had a renal biopsy which showed diffuse foot process fusion and in keeping with a diagnosis of FSGS (focal segmental glomerulosclerosis).

What would be next immediate steps in this patients management?

A. Start this patient on ACEi or ARB
B. Start this patient on Cyclosporine
C. Repeat 24 hour urine collection in 3 months
D. Do nothing 



ANSWERS


1-b – This patient very likely has nephrotic range proteinuria and will need a 24 hour urine collection for protein for further assessment. He very well may have nephrotic syndrome and further bloodwork can be done for evaluation of such. NSAID use as in this case is associated with membranous nephropathy which can result in nephrotic syndrome.


2-d  Uncontrolled hypertension is a contraindication to proceeding with a biopsy for this patient. The blood pressure should be controlled with antihypertensives before the proceed so as to limit any significant risk of bleeding after.


3-c This patient recently completed a course of gentamicin which is known to cause toxic ATN.  This patient has a relatively bland urinalysis with no signs of RBC casts on the microscopy to suggest RPGN. Also, with Fanconi’s syndrome there is an abnormality in the proximal tubular function resulting in significant glucosuria (in the presence of normal serum glucose), aminoaciduria, phosphaturia and bicarbonaturia either due to inherited or acquired causes such as multiple myeloma.


4-a This patient has idiopathic non-nephrotic FSGS. The HIV test was negative and HIV is typically associated with a collapsing variant of FSGS also called the HIV-AN (associated nephropathy). Additionally, her lupus and Hepatitis tests were also negative which also cause secondary FSGS.  This patient should be started on an ACEi or ARB to see if the degree of proteinuria can be improved. If she approaches nephrotic range proteinuria in the future then she may need corticosteroid therapy. However close to 50% of patients are either relapsing corticosteroid-dependent or resistant and likely require immunosuppression with a calcineurin inhibitors.   Read more about FSGS here on medscape.

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