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Infection-Associated Glomerulonephritis

A 60-year-old male presents with a painful left hip, hematuria, and a creatinine of 1.5 mg/dl. He was recently hospitalized due to fever and chills. It was found that his left hip implant was infected. Blood cultures grew out methicillin-resistant Staphylococcus aureus. After beginning treatment with antibiotics and planning for surgery, a nephrology consult was requested. A kidney biopsy was performed and serologies were ordered. Figure 1 shows segmental endocapillary hypercellularity. Figure 2 shows mild interstitial fibrosis. Figure 3 shows staining with C3 only. All other immunofluorescence stains were negative on the frozen tissue. Immunofluorescence was then performed on the...

IgA Dominant Infection-Associated Glomerulonephritis

A 65-year-old male presents to the ER with a new onset rash and blood in his urine. The ER doc is worried about an allergic reaction and on chem 7 finds that the patient’s creatinine is 6.5 mg/dl. The patient has been a diabetic for over 20 years and had been diagnosed with cellulitis of his left foot a week ago by a family practice physician who gave him antibiotics. A skin biopsy of the new onset rash during this hospitalization shows a leukocytoclastic vasculitis with IgA deposition. A kidney biopsy is requested. The kidney biopsy shows nodular diabetic glomerulosclerosis...

Pushing Glass (December 7, 2018)

The patient is a 50-year-old female who presents 2 days after a renal transplant with a delay in graft function and a creatinine of 7. Her end-stage renal disease was due to diabetic glomerulopathy. She was on dialysis for 3 years. She received a kidney from a 22-year-old deceased donor (motorcycle accident). The kidney at time of transplant looked normal grossly and microscopically. What is the most likely cause of the patient’s delay in graft function? A. Acute Cellular Rejection B. Surgical manipulation of a vessel C. Recurrent diabetes D. Donor-derived disease   The correct answer is (B) surgical manipulation...

Pushing Glass (September 7, 2017)

The patient is a 75-year-old female who presents with proteinuria and a creatinine of 2.50. She has chronic lymphocytic leukemia, hypertension, and multiple sclerosis. What is the best diagnosis? A. Type I Cryoglobulinemia B. Type II Cryoglobulinemia C. Hepatitis C associated MPGN D. C3 Glomerulonephritis   The best answer is A (type 1 cryoglobulinemia). The biopsy shows a membranoproliferative pattern with IgG lambda restriction. The presence of hyaline thrombi is concerning for cryoglobulinemia. Cryoglobulins are immunoglobulins that precipitate in the cold and dissolve on warming and induce disease via vascular injury and blockage. Three types of cryoglobulins are distinguished based...

Pushing Glass (June 22, 2018)

The patient is an 80 year-old male who presents with fatigue and a creatinine of 6.5 mg/dl. He was in his normal state of health until he and his grandchild went to the park on a hot afternoon. Subsequently, he began to feel ill and fatigued and went to see his physician. He has a past medical history significant for long-standing hypertension which is treated with a loop diuretic. Based on this history and images, what is the best diagnosis? A. Waldenstrom macroglobulinemia B. Light Chain Deposition Disease secondary to lymphoplasmacytic lymphoma C. Light Chain Deposition Disease secondary to small...

Pushing Glass (May 25, 2017)

The patient is a 74 year-old female who presents with a sudden rise in creatinine to 5.0. A week ago at her annual physical, her creatinine was 1.0. She presents to the hospital with dehydration and flu like symptoms. She has a history of hypertension and CLL which is followed by oncology. What is the best diagnosis? 1. Acute interstitial nephritis 2. Chronic lymphocytic leukemia 3. Large B-Cell Lymphoma arising from chronic lymphocytic leukemia 4. Acute tubular injury The best answer is (Answer 3) Large B-cell lymphoma arising from chronic lymphocytic leukemia. The biopsy shows a very brisk interstitial infiltrate...

Pushing Glass (April 6, 2018)

A 75-year-old Hispanic male presents with a creatinine of 3. His creatinine has slowly been creeping up over the last year from 1.8 to the current level. No hematuria or proteinuria is reported. Serologies for ANA, dsDNA, rheumatoid factor, hepatitis B, hepatitis C, and ASO are negative. Complement levels are normal. SPEP and UPEP are within normal limits. What is the best diagnosis? A. Arterionephrosclerosis B. Amyloidosis, AL-Type C. Amyloidosis, AA-Type D. Amyloidosis, ALect2-Type   The best answer is D (Amyloidosis, ALect2-Type). From low power, the glomeruli have an ischemic appearance and the arteries have severe arteriosclerosis. However, the Congo...

Pushing Glass (March 13, 2018)

A 65-year-old male presents with mild proteinuria and a sudden increase in creatinine. He was recently diagnosed with widely metastatic gastric carcinoma and has received 4 rounds of chemotherapy. During treatment with chemotherapy, his creatinine increased to 3.5 and has remained at that level despite fluid resuscitation. A kidney biopsy is performed. What is the best diagnosis? A. Membranoproliferative Glomerulonephritis B. Metastatic Gastric Carcinoma C. Intravascular Diffuse Large B-Cell Lymphoma D. Thrombotic Microangiopathy The best answer is C – Intravascular Diffuse Large B-Cell Lymphoma This is a very difficult case due to the proliferative nature of the glomeruli. At first...

Pushing Glass (January 12, 2018)

A 70-year-old female presents with 8 grams of proteinuria and a creatinine of 2.1. She relays that she has noticed a gradual increase in swelling over the last 6 months. She denies NSAID use and any new exposures. What is the best diagnosis? A. Cryoglobulinemia B. IgA Nephropathy C. Post-infectious Glomerulonephritis D. Thrombotic Microangiopathy The best answer is A – cryoglobulinemia. The photographs show a membranoproliferative glomerulonephritis with numerous hyaline thrombi. The hyaline thrombi stain for IgM, IgA, kappa, and lambda. The best diagnosis is cryoglobulinemia. IgA nephropathy is a consideration, but IgA nephropathy typically has mesangial staining and usually...

Pushing Glass (October 10, 2017)

The patient is a 50-year-old African-American female with a past medical history significant for ESRD secondary to lupus nephritis who presents two weeks after a renal transplant with a delay in graft function. Her creatinine at the time of presentation is 9. She reports feeling fine and does not have any rashes or joint discomfort. A renal biopsy is performed on the transplanted kidney. Which is the best diagnosis? A. Acute Tubular Injury B. Thrombotic thrombocytopenic purpura C. Acute Antibody-Mediated Rejection D. Vasculitis  The correct answer is c (acute antibody-mediated rejection). The biopsy shows a constellation of findings. This includes...