Clinico-Pathological Conference on Acute Kidney Injury in a Patient with Nephrotic Syndrome

Dr. Orozco: The patient is a 57-year-old female patient who presented to the emergency room with rapid onset of lower extremity edema. She denied any other systemic symptoms. Her past medical history was significant for vascular headaches and springtime allergies. Medications included calcium, vitamin D supplementation and desloratadine. Physical examination revealed a healthy-looking woman in no apparent distress. Her blood pressure was 140/90 mm Hg, heart rate 80 per min and a temperature of 37 ° C. The remainder of the examination was unremarkable, except for 2++ edema in the lower extremities. Laboratory evaluation was as follows: urinalysis showed specific gravity 1,030, pH 6.0, blood ++, albumin . Urine microscopy showed: 70 red blood cells/high-power field (RBCs/HPF), few hyaline casts and several fat droplets but no cellular casts. The urine albumin-to-creatinine ratio was high: 12,468 (normal value ! 30). Electrolytes were within the normal range, Blood urea nitrogen was 28 mg/dl, serum creatinine was 0.9 mg/dl (80  mol/l), corresponding to an estimated glomerular filtration rate of 60 ml/ min/1.73 m 2 by the four-variable Modification of Diet in Renal Disease (MDRD) equation. A serum creatinine test taken 3 months earlier was 0.74 mg/dl (65  mol/l). The hemoglobin was 13 g/dl, leukocyte count was 13,960/ l, platelet count was 150,000 and erythrocyte sedimentation rate was 18 mm/h. Liver function tests were all normal. Serum albumin was 2.5 g/dl, total cholesterol was 279 mg/dl (7.3 mmol/l) with an LDL cholesterol concentration of 213 mg/dl (5.5 mmol/l; normal value ! 130 mg/dl or 3.3 mmol/l). D -dimer concentration was elevated at 3.75  g/ml (normal value ! 0.5  g/ml). Immunologic data showed an antinuclear antibody titer of 1/40. Results of antineutrophil cytoplasmic antibodies, anti-double-stranded DNA antibodies, C3/C4 compleBiography