Would you biopsy him?

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Hi:I Have been seeing this patient for the last 2 months:67 WM with stable CKD stage IIIB, S Cr 1.8, GFR 40, and New onset nephrotic syndrome of 5 grams confirmed on 24 hour urine collection, Repeat UPCR showed 5.5 gm/day.PMH: Malignant HTN, Diet controlled DM; A1c 6%, No Diabetic Retinopathy, CKD, CAD, DyslipidemiaBP 170/110 on ABPM, Clear lungs, B/L LE edema of ++Na, K, Hco3 Normal, Scr stable at 1.8 for one year, Hx of negative proteinuria 3 years ago; 300 mg/day on 24 hour proteion collection, this was repeated few weeks ago FOR WORSENING BP control and LE Edema and now its 5.5 grams, LDL 150, Alb 3, UA: ++++ Protein, negative RBC, negative WBC.ANA, RF, HBSAg, HBSAb, HCVAb, UPEP, SPEP, Freelite Assay, C3, C4, CH50, HbA1c, H/H, WBC, Platelets, Colonoscopy 5y ago: all are Within Normal.Renal US: B/L diffuse small cortical Cysts, Rt kidney 12 cm, Left kidney 12.5 cm, No Hydro. Radiologist: This isn't PKD.Abdomen MRI: B/L diffuse few mm sized cortical Cysts.Besides controlling BP, treating fluid overload, lowering lipids, and maximizing ACEI/ARB, What would you do? Would you biopsy this man?Mohammad Samih, MDHarlan, KY, USA 
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    • Accepted Answer

      Tuesday, January 24 2012, 05:57 AM - #Permalink
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      Hello,

      I can only speak generally of course and can't give specific medical advice about a case for liability reasons. However, in general, with normal sized kidneys and very high grade proteinuria, despite a history of hypertension as a possible explanation, I think one needs to exclude a primary glomerulonephritis. Having said this, it is very possible that severe hypertension alone is causing this presentation. As well, prior to biopsy, of course, BP needs to be well controlled.

      I would definitely like to hear what happens with this case.
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      • Accepted Answer

        Tuesday, May 22 2012, 04:07 AM - #Permalink
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        Is it new onset nephrotic syndrome or just nephrotic range proteinuria, I would definitely biopsy him it was the former, may think a bit more if it was the latter
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