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Archive: Digging Deeper

Digging Deeper, or How We Never Quit

We received the biopsy from a 25-year-old female who presented for evaluation of nephrotic range proteinuria.  Lab evaluation reveals a creatinine of 0.55 and 24-hour urine protein is 3.6 g.  Serologies were negative or normal for ANA, hepatitis B, hepatitis C, HIV, and complement levels.  There was no history of hypertension or diabetes. A biopsy was performed to evaluate the source of proteinuria. Two cores of renal tissue were sampled on light microscopy evaluation.  They consisted mostly of medulla, and only two glomeruli were seen in multiple sections. The glomeruli have capillary loops with attenuated contours. The capillary loops appeared...

Digging Deeper – Here, There, and Everywhere

This biopsy came from an elderly gentleman in his 80s, who presented with acute renal failure.  His serum creatinine had increased from a baseline of 1.3 mg/dL up to 6.6 mg/dL.  And in addition to that, urinalysis was positive for proteinuria and blood.  His medical history included pulmonary embolism, BPH, gastrointestinal hemorrhage and GERD.  Multiple serologies were ordered upon presentation, and among these, pANCA and MPO were markedly positive.  A biopsy was performed to investigate the possibility of an ANCA-mediated crescentic glomerulonephritis. Unfortunately, the material obtained for biopsy was small in size, and the longest core, submitted to light microscopy,...

Step By Step

The biopsy is from a 65 year-old female who presented with acute renal failure and elevated creatinine up to 1.9 mg/dl.  She has non-ischemic cardiomyopathy and protein electrophoresis is positive for lambda light chains.  Serologies for ANA and rheumatoid factor are within normal limits.  A biopsy was performed to rule out paraprotein associated disease and there was a specific concern for amyloidosis, due to cardiac changes. The biopsy consisted of a good sample, contained multiple cores of tissue and more than 20 glomeruli.   The glomeruli were very unremarkable by light microscopy – loops were open, with regular contours, and no...

Not Quite Nodular

This biopsy came from a 70-year-old gentleman with acute renal failure. He had a known history of diabetes, hypertension, and chronic kidney disease.  His baseline serum creatinine is between 1.7 mg/dl and 1.9 mg/dl and was found to be elevated up to 2.9 mg/dl. Proteinuria was quantified as 0.2 g/g on urine protein to creatinine ratio.  Urinalysis showed trace blood and protein.  While processing the clinical information, one has to admit that this clinical presentation is not an unusual one.  A fair number of patients will have a decline in renal function that reflects the reality of an already struggling...

One little, two little, three little findings…

This biopsy came to us for evaluation of nephrotic syndrome. The patient is a Hispanic gentleman in his late 80s, with CKD stage IV and a history of arthritis, diabetes mellitus, coronary artery disease, and hypertension.  He had 4.9 g/g of proteinuria.  He had negative ANA, hepatitis B, and C serologies. C3 and C4 were within normal limits. Clinically, the differential diagnosis included membranous glomerulopathy and FSGS. The biopsy was a very good sample, consisting of long cores of renal tissue, mostly from cortex.  More than 20 glomeruli were present.  The glomeruli had clear features of diabetic nephropathy, as expected...

Digging Deeper, Literally

This biopsy came from a 79-year-old patient. He had presented with acute renal failure. His serum creatinine was up to 2.0 mg/dL, from a normal baseline. He also had proteinuria, which was quantified as approximately 1 g. His serum albumin was low at 2.5 g/dL. The patient was anemic, and hemoglobin was 9.1. The patient had been investigated with an extensive serologic work up. ANA was negative, C3 was within normal limits, and SPEP was negative for monoclonal proteins. However, ANCA serologies were positive. Based on that, the patient had been treated with high doses of steroids for a few...

A Case of an Unlucky Strike

This biopsy was from a 57-year-old African American female patient. She presented with a gradual increase in serum creatinine over the course of 5 months. Initially, her baseline serum creatinine was 1.3 mg/dl but two months later it increased to 2.0 mg/dl. And, at the time of the biopsy, an additional 3 months later, her serum creatinine was as high as 4.4 mg/dl. During her workup, she was found to have nephrotic syndrome with proteinuria quantified at 8 gm/24hr, a serum albumin of 1.3 g/dL, and ascites.  Concerning previous medical history, the patient had a diagnosis of stage II colon...

Hidden Treasures

This biopsy came to us due to acute renal failure and proteinuria. The patient was a gentleman in his late 70s, with elevated creatinine up to 2.0 mg/dl, and proteinuria quantified at about 1 gram per 24 hours. His serum albumin was remarkably low, at 2.5 g/dL. He was also anemic, with hemoglobin at 9.1 g/dL. ANCA serologies were positive and the patient had been treated with high doses of steroids for a few weeks prior to the biopsy. SPEP was negative for monoclonal proteins. ANA serology was negative. Fortunately for us, the biopsy was a great sample of renal...

When Lightning Strikes Twice

This biopsy came to us for a workup on proteinuria.  The patient is a 68-year-old female with a history of “low-grade non-Hodgkin’s lymphoma” initially diagnosed in 2007. She was treated with rituximab, from November 2007 to July 2009.  She was treated with Treanda (bendamustine ) during the spring of 2010.  In 2010, she presented with proteinuria and a renal biopsy established the diagnosis of membranoproliferative glomerulonephritis (MPGN).  Her symptoms resolved with chemotherapy and lymphoma treatment and remission.  She now presents once again with proteinuria. The patient is in remission from the lymphoma. A renal biopsy was performed to establish the cause...