A 35 year-old Caucasian male presents with persistent swelling of both legs associated with dark colored urine for two months. He went to an emergency room 2 months ago for these complaints and was told that he has some protein and blood in the urine. He was treated with 3 days of levofloxacin. There is no other past medical history. No history of skin rash or joint swelling. On examination the blood pressure was 130/85 mm Hg and there was bilateral 1+ pedal edema. Rest of the physical examination was normal. Urine analysis showed 3+ proteinuria, 10-15 RBCs per high-power field, and occasional RBC cast. The BUN was 10 mg/dL, serum creatinine was 0.9 mg/dL. Antistreptolysin was negative, C3 level is decreased and C4 level is normal. Antinuclear antibodies, ANCA, hepatitis B and C serology were negative. 24-hour urine collection showed 2 g proteinuria and a kidney biopsy was performed. On light microscopy, kidney biopsy showed increase in the mesangial matrix and cellularity and glomerular basement membrane appeared irregularly thickened. Silver stain revealed duplication of glomerular basement membrane in multiple glomeruli. Immunofluorescence showed positive staining for C3, but negative for IgG, IgM and IgA. Electron microscopy revealed electron-dense deposits in the mesangium and sub-endothelial area.
What is the most likely diagnosis?
Copyright © ABIM Exam World Created On: 09/12/2017 Last Modified: 03/07/2021
A 68-year-old gentleman, Caucasian descent, comes to clinic for follow up visit. He is known to have type 2 diabetes mellitus for the past 18 years. His father had diabetes from 40 years of age and developed kidney disease requiring dialysis after 15 years of diabetes. He reports no symptoms. He has been having hypertension and coronary artery disease with history of PCI 2 years ago. He has non-proliferative diabetic retinopathy. His medications are sitagliptin, gliclazide and metformin in addition to losartan and hydrochlorothiazide. He has been monitoring blood sugar at home and reports no hypoglycemia. He exercises at least at least 30 minutes per day. His vitals recording shows BP of 168/66 mm Hg. His BMI is 29.2. Systemic examination is unremarkable.
His laboratory investigation is reported as follows.
Characteristic
value
Hemoglobin
12.2 gm/L
WBC count
6.8 X 103/cubic mm
Platelet count
241 X 103/cubic mm
Segmented Neutrophils
Lymphocytes
Monocytes
Band neutrophils
Eosinophils
Basophils
60%
36%
2%
0%
Sr. Sodium
139 mEq/L
Sr. Potassium
4.9 mEq/L
Sr. Creatinine
1.2 mg/dL
Sr. Bicarbonate
22 mEq/L
Sr. Chloride
101 mEq/L
Total Bilirubin
1.0 mg /dL
AST
16 U/L
ALT
18 U/L
Sr. Albumin
4.0 g/dL
HBA1C
7.8%
Sr. Calcium
10 mg/dL
Urine dipstick
pH- 5.4
Albumin-trace
no blood
no WBCs
24-hour urinary albumin
200 milligrams/day
What is the MOST LIKELY correct statement regarding clinical diagnosis of Diabetic Kidney Disease in this patient ?
The Correct Answer is Option D: Family history of Diabetic Kidney Disease is associated with renal involvement in Diabetes.
Explanation:
Familial studies have demonstrated clustering of diabetic nephropathy. Patients with DM with a first-degree relative with T1/T2DM and diabetic nephropathy have more risk for developing diabetic nephropathy than those without an affected relative. This familial clustering has also been well documented in the Pima Indian population. The candidate genes identified are glucose transporter 2(GLUT2), transforming growth factor beta (TGF- ?), and endothelial nitric oxide synthase (eNOS).
Option A: Diabetic nephropathy is a clinical syndrome characterized by the following:
· Persistent albuminuria (>300 mg/d) that is confirmed on at least 2 occasions 3-6 months apart
· Progressive decline in the glomerular filtration rate (GFR)
· Elevated arterial blood pressure
Hence kidney biopsy is not a mandatory investigation to diagnose diabetic kidney disease.
Option B: If the amount of urine albumin exceeds 30 mg/d and is less than 300 mg/d it is called microalbuminuria, and if it is greater than 300 mg/d it is called macro albuminuria or overt albuminuria. Microalbuminuria is present in 5-7% of normal individuals and is associated with cardiovascular mortality and morbidity. It is marker of endothelial dysfunction in type 2 diabetes mellitus. Presence of microalbuminuria alone with diabetes cannot be clinically diagnostic of diabetic kidney disease.
Option C: Micro hematuria has been demonstrated in biopsy studies with isolated diabetic nephropathy. Red blood cell casts have also been described in patients with diabetic nephropathy. However, it is important to rule out other glomerular and extra-glomerular causes of hematuria.
Copyright © ABIM Exam World Created On: 10/31/2018
A 60 year-old with recently diagnosed colon cancer and diabetes presents with bilateral pedal edema, BP is 120/80 mm Hg, Urinalysis showed 4+ protein, no RBCs or WBCs, and 8-10 Hyaline casts. His BUN is 20, Creatinine is 1 mg/dL, and albumin is 2 grams/dL. 24 hour urine collection showed 10 grams protein. The patient undergoes kidney biopsy. The EM is shown below :
The correct answer is E
Membranous Nephropathy.
The Electron microscopy shows subepithelial electron dense deposit as classically seen in membranous nephropathy. If in the question there is a suggestion of colon, breast, or lung cancer, then the glomerulopathy is usually membranous. After that look for other findings on histopathology which will confirm the diagnosis. Subepithelial electron dense deposits.
BOARD POINT - FAMILIARIZE YOURSELF WITH THESE ASSOCIATIONS :
1. Solid cancers (colon, breast, lung, renal) plus proteinuria = Membranous nephropathy
2. Hodgkins lymphoma plus proteinuria = Minimal change disease
3. HIV plus proteinuria = Focal segment glomerulosclerosis FSGS
4. Pamidronate plus protenuria = FSGS (rare)
5. Myeloma, no albuminuria on dipstix, but proteinuria on protein/creatinine ratio or 24 hrs urine: Light chain nephropathy
6. Myeloma with non specific proteinuria (on dipstix, urine protein/creatinine ratio and 24 hrs urine): Light chain nephropathy or amyloidosis.
BOARD POINT - FAMILIARIZE YOURSELF WITH THESE HISTOPATHOLOGY ASSOCIATIONS FOR VARIOUS GLOMERULAR DISEASES
Copyright © ABIM Exam World Created On: 09/20/2017 Last Modified: 08/29/2018
The ACCOMPLISH trial is the first major trial addressing the issue of combination therapy in 11,506 patients who were at high cardiovascular risk. The goal blood pressure was less than 130/80 mm Hg in the patients with diabetes or impaired renal function, and less than 140/90 mm Hg in the patients with prior cardiovascular disease.
Which of the following combinations of blood pressure medications was the best in reducing cardiovascular events and slowing the progression of nephropathy in patients with hypertension who were at high risk for such events?
Copyright © ABIM Exam World Created On: 09/20/2017 Last Modified: 01/25/2021
A 25 year-old female is referred by her primary care provider for evaluation of hypertension and hypokalemia. The primary care provider has already started her on oral potassium, despite therapy her Potassium being 2.8 meq/L. Her blood pressure despite treatment with amlodipine and Lisinopril 154/96 mm of Hg. There is no renal bruit. Systemic and fundus examinations are normal. Her mother was also diagnosed with hypertension at an early age. Her brother died of a cerebrovascular accident 2 years ago. Laboratory findings are as follows:
Na 140
Potassium 2.8
Chloride 100
HCO3 26
BUN 15
Creatinine 0.8
Glucose 110
TSH and Cortisol are normal
ACTH elevated
Renin 0.7 (Low)
Aldosterone 48 (elevated)
Urinalysis:
Sodium 240 mEq/D
Potassium 98 mEq/D
Urinary 18-OH Cortisol and 18-oxocortisol are elevated.
The most appropriate treatment for this patient is:
Copyright © ABIM Exam World Created On: 09/20/2017 Last Modified: 08/06/2018
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