PGY4 Julian Hirschbaum presented a case of a 73 year old male with history of ischemic cardiomyopathy, HFrEF 55%, CAD s/p stent in LAD, HTN, BPH, and GERD presents with 1 day of worsening abdominal pain, nausea and vomiting. The patient has had 8 month history of intermittent diffuse abdominal pain that is now acutely worsened. He rates it as 9/10 in severity and is exacerbated by food and medication and associated with daily nausea and NBNB emesis. +9 months of whole body swelling. +DOE after 1 block of ambulation and occasional SOB wen lying supine.
Home Meds: ASA 81mg qday, Atorvastatin 80mg qday, Carvedilol 25mg BID, Amlodipine 5mg qday, Clopidogrel 75mg qday, Omeprazole 20mg qday
SH: Born in Jalisco, Mexico. Incarcerated for 2 years. Remote history of tobacco and alcohol use. No history of illicit drugs.
Vitals: T 36.8, HR 73, RR 18, BP 161/82, O2 sat 99% on RA
Physical Exam: mild bilateral crackles in lower lung fields, normal cardiac exam, mildly distended abdomen, 3+ pitting edema to thighs, +pitting edema in b/l UE, scrotal sac diffusely swollen
CBC: WBC 7.2> Hb 13.4/Hct 38.1 <Plt 169 (MCV 91.5, RDW 12.2%)
Na 137/K 4.4/Cl 105/HCO3 25/BUN 24/Cr 2.27<Glucose 123
ALP 84>T.protein 4.3/Albumin 1.9/AST 22/ALT 12/Tbili 0.2/Dbili <0.2
Ca 7.7. Mg 2.2, Phos 4.4
Coags: PT 13.5, INR 1.04
Infectious workup including BCx, UCx, procal, RPR, HIV, hepatitis panel negative.
- UA with 300 protein, 250 glucose, trace ketones and large blood (11-25 RBCs); negative leuk/nitrites
- FeNa: 7.1%
- FeUrea: 109.3%
- U24H protein: 10.75g/24 hours
- Renal US: normal echogenicity in the kidneys, small bilateral pleural effusions
- SPEP: no monoclonal proteins identified by immunofixation
- UPEP: abnormal band in the beta region
- K/L: 3.27
- Anti-PLA2R positive
Rheum labs negative for ANA, ANCA, Anti-GBM and normal complement levels.
Renal Biopsy: Membranous nephropathy, stage 2 of 4; PLA2R staining is positive
Treatment: Patient started on IV diuresis and symptomatically improved. Discharged with follow up with renal.
- Membranous nephropathy is characterized by basement membrane thickening and the presence of electron dense deposits across the GBM.
- In determining the etiology of MN, secondary causes such as malignancy, SLE, drugs and infection must be ruled out.
- Primary MN is now considered a renal-limited autoimmune disease, with antibodies against PLA2R identified in 70-80%.
- Treatment of primary MN relies on use of immunosuppressive agents such as glucocorticoids, alkylating agents, calcineurin inhibitors and the anti-CD20 monoclonal antibody, Rituximab.