PGY3 Jeanney Kang presented a case of a 52 year old male with history of CPC-C, MELD-Na 33 cirrhosis 2/2 alcohol, complicated by ascites, SBP and esophageal varices, Type 2 diabetes mellitus and hypertension who presents with worsening, diffuse abdominal pain x4 days. He reports increased abdominal distention and describes the pain as “pressure-like”. At the same time, he has had multiple episodes of nonbloody, nonbilious vomiting and non-bloody, mucous like diarrhea. He also reports a decrease in urine output followed by no urine output for last 2 days. He has not been eating or drinking since the onset of symptoms due to vomiting. Denies any sick contacts or recent travels. Home medications include furosemide, spironolactone, losartan and metformin. He drinks 4-12 bottles of beer daily, for >10 years. Denies any tobacco or drug use. Works at a restaurant kitchen.
Vitals: T 36.8, HR 71, RR 15, BP 132/74, O2 sat 98% on RA
Physical Exam significant for A&Ox4, +scleral icterus, normal cardiac and pulm exam, abdomen moderately distended with +shifting dullness. No abdominal bruit. No peripheral edema, joint pain or skin rashes noted.
CBC: WBC 2.6> Hb 11.3/Hct 31.8 <Plt 41 (MCV 93.2, RDW 16.4%)
Na 122/K 4.8/Cl 89/HCO3 15/BUN 76/Cr 7.54<Glucose 437 (baseline Cr 0.9 about 5months prior)
ALP 271>T.protein 5.9/Albumin 3.6/AST 31/ALT 40/Tbili 4.6/Dbili 3.4
Ca 7.6, Mg 2.1, Phos 6.1
Coags: PT 16, INR 1.3, PTT 34.1
Infectious workup initiated, with the following findings:
- BCx negative
- Ascitic fluid: 84 nucleated cells, albumin 1.5 g/dL, protein 2.5 g/dL
- Ascitic fluid gram stain and culture negative
- Hepatitis viral panel negative
- HIV negative
- Lactate 1.1
Renal/Rheum workup initiated, with the following findings:
- UA: protein >300, glucose 100, ketones trace, large bili, large blood (>50 RBC), positive nitrite, moderate leuks (4-10/HPF)
- Urine protein/cr: 2
- Sosm 299 mOsm/kg
- ANA negative, dsDNA negative
- ANCA negative
- C3 10 (normal 90 – 180), C4 7.5 (normal 10 – 40), CH50 <13
- RF <10
- Anti-GBM <1
- Cryo negative
- HbA1c 10.6%
- SPEP: no abnormal bands; UPEP: no abnormal bands
Abdominal US shows hepatic cirrhosis with features of portal hypertension. No focal hepatic mass is identified. Mild to moderate volume of ascites.
Renal biopsy done showing proliferative crescentic glomerulonephritis, immune complex type. C3 predominant with a coarse granular pattern.
Treatment: Due to minimal urine output, vascath placed and patient was initiated on hemodialysis. Given renal biopsy results concerning for post-infectious GN, he was given pulse steroids followed by PO steroid taper.
- Post-infectious GN is immune mediated, triggered by prior infection (classic is post-strep but can be other infections).
- Symptoms/labs: nephritic syndrome, low complements, AKI
- Pathology: diffuse proliferative and exudative GN with IF showing granular “starry sky” deposition of C3
- Treatment: supportive care, HD and if more than 30% crescents on renal biopsy, can treat with steroid pulses.