Nephropathology Specialty Conference

Case #2

The 53-year-old male of Guyanese origin suffered a severe motor vehicle accident three years before presentation, and was on disability leave. Musculo-skeletal pains were treated with Robaxisal that was taken regularly for one year prior to presentation. Arterial hypertension was diagnosed and treated during the same year with a calcium channel blocker and an ACE inhibitor agent. The patient had no complaints other than mild swelling of lower extremities. The patient was referred to a nephrologist for an elevated serum creatinine level (2.5 mg/dl), and a recent onset of proteinuria (3.4g/24 hour urine), and hematuria.

At the first visit, the medical history was negative for jaundice, hepatitis, arthritis, rash, photosensitivity, and Raynaudís phenomenon. There was no personal or family history of kidney disease. The patient was instructed to discontinue Robaxisal. He was to be seen again in two weeks but failed to return until one month later. At that latest visit, review of the laboratory values indicated a creatinine of 4.5 mg/dl, hypoalbuminemia; hypercholesterolemia, ANA titer at 1:80 with a homogeneous pattern, complement fractions C3:0.88 g/L (normal: 0.88-2.01) and C4:<0.10 g/L (normal: 0.16-0.47); hemoglobin: 130 g/L; WBC: 7.8 x 10⁹/L; platelets: 252 x10⁹/L; alkaline phosphatase: 99 U/L (normal: 40-122); SGOT: 25 U/L (normal: 5-45). Hepatitis serology was negative for hepatitis B surface antigen (HbsAg) but revealed the presence of hepatitis B surface and core antibodies (anit-HBs and anti-HBc). Hypoalbuminemia and a polyclonal gammopathy were found on protein electrophoresis. The patient was admitted to hospital for a percutaneous renal biopsy.

In hospital, additional investigations disclosed a creatinine of 6.3 mg/dl, complement fractions C3:0.78 g/L and C4:<0.10 g/L, and negative anti-ds DNA. The patient was treated empirically with pulse methylprednisolone, switched later to oral prednisone. At the time of discharge, the creatinine level was 3.5 mg/dl; one month later, still in prednisone, the creatinine level was 2.0 mg/dl. However, the patient remained nephritic and edematous; Cyclophosphamide was added to the therapeutic regimen. Partial remission of the nephritic syndrome was induced within two months after the initiation of Cyclophosphamide.