73 year-old man with 7.5 grams of urinary protein per day.
[b]Past Medical History:[/b]
[*]Hypertension x decades
[*]Diabetes (HbA1C 6%, no complications)
[*]Prostate cancer PSA now, on hormonal replacement Apparently in 'remission'
Presented to family doctor complaining of edema. Otherwise asymptomatic.
Blood pressure 160/70, hypervolemic with bilateral lower limb edema
Creatinine 175 umol/L, electrolytes normal. Blood glucose normal with HbA1C 6%. LDL 7.2 mmol/L, normal triglycerides. SPEP, calcium normal. Serum albumin 20 g/L. 24 hr urine protein 7.5 grams, normal urine protein electrophoresis. ANCA, ANA, AntiGBM normal, Hep B/C/HIV negative. Chest xray normal. Ultrasound shows normal kidneys, 10 cm bilaterally. Chest xray normal. Colonoscopy normal.
Sections show kidney tissue consisting of cortex. Up to 16 glomeruli are present in the specimen. No glomeruli are globally sclerosed. Most glomeruli are enlarged and have mild mesangial hypercellularity. There are no crescents. The mesangial matrix is increased in some glomeruli, with no lobular changes. The capillary wall thickness is increased.
The silver stain does not show spikes on the outside of the glomerular basement membrane. There is moderate interstitial fibrosis. Interstitial fibrosis has a diffuse distribution. The juxtaglomerular arterioles are normal. Arteries are present in the specimen and show no abnormalities. The tubules are atrophic in some areas. Immunofluorescence shows peripheral granular deposits of IgG (2+) and C3 (2+).
ELECTRON MICROSCOPY shows conspicuous subepithelial electron dense deposits surrounded by spikes extending from the GBM.
This patient was observed for a 3 month period with a trial of dose escalation in ACE and ARB. Despite this, proteinuria persisted and renal function gradually deteriorated. I considered him to be high risk for progression to end-stage renal disease.
[b]My concern of course is that:[/b]
[*]He has a recent malignancy
[*]He has impaired renal function
[*]He is relatively elderly with significant comorbidity.
[*]Treat with immunotherapy
[*]If yes, which agent?
[*]Or, would a recent malignancy dissuade you
Help is appreciated!