master class

1. Dr. Ibrahim Elnagar
Nephrology Resident
New Mansoura General Hospital

2. A-30 year old patient from Elmahala single ,driver
smoker(2 pack)/day , addict for heroin ,marijuana
and tramadol
Personal History

3. Swollen of both lower limb ,shortness of breath
2 weeks ago
Complaint

4. • 2 weeks before admission, patient developed
lower limb edema associated with decreased
urine output, puffiness of eye lids, dyspnea and
bone aches.
• Also the condition associated with persistent
vomiting about four times per day , nausea ,
epigastric pain and decrease oral intake ,with no
diarrhea or fever
• The condition wasn’t associated with redness or
hotness or any skin lesions on the overlying skin
Present History

5. Patient seeked medical advice
Non-specific TTT: PPI, antiemetic,
However,
No improvement
Lab investigations were ordered
Serum Creatinine 7.5 mg /dl

6. • No history of DM or HTN
• No history of renal disease or liver disease
• No history of immune disease
• No history of radio contrast
• No history of traveling abroad
• No history of previous surgery or blood
transfusion
Past History

7. History of tramadol abuse about 4
tabs per day for 5 years ,Hashish
for 5 years ago and heroin
addiction for 1 year
History for NSAIDS occasionally
,but not in the last 2 weeks before
admition
History of proton pump inhibitors
,anti emetic in the week before the
admition
Drug History

8. • Fully conscious
• BP: 150/100
• Pulse: 84/min sinus
• RR: 22/min
• No fever, rash or arthritis
• neck veins: congested
• Chest: wheeze with bronchial breathing
• Abdomen: lax ,no tenderness
• Edema LL grade 3 with no redness or hotness on
the overlying skin ,
Examination

9. • CBC :
• HB :11.7gm/dl
• WBS:16c/mcl
• PLT:150 c/mcl
• KIDNEY FUNCTION:
• S. Creatinine : 8.2mg/dl S.Urea: 132mg/dl
• Urine analysis:
• showed: protein ++ RBCs 8-12 pus 50-60
Lab Results

10. • ABG and electrolyites
• Ph:7.35 h2co3:15 pco2: 26
corrected ca :8.7mg/dl
• Po4: 6mg/dl
• Liver function: Albumen: 2.7gm/dl SGPT: 320
SGOT:180
bilirubin:2.5 (direct0 .7) INR 2
• Virology hcv+ve HBV-ve HIV --ve
• Inflamatory markers :
• ESR:127
• CRP :96
Lab Results

11. Radiology
1- Abdominal us
• Both kidneys mildly enlarged and swollen with
increased cortical echogenicity
• (RT: 12.9 x 5.5 LT: 12.5x5.2)
• Average parenchymal thickness
• No stones , backpressure ,or mass are seen
• Otherwise , abdominal US completely normal
2-Trans-thorasic ECHO
No vegetation or thrombus with overall cardiac
indices within normal
Radiology

12. 3-chest x ray
Bilateral obliteration of CPAs , Increase BVM

13. 2:acute tubular necrosis
1:acute interstitial nephritis
3:HCV related nephropathy
4:TMA
5:FSGS
Differential Diagnosis

14. • ANA : -ve
• C3: normal
• C4: normal
• pANCA:-ve
• cANCA:-ve
• RF factor 1/8
• LDH:600
• Blood film : no shictocytis . no abnormal cells
• Alb/creat :890 mg/mmol (normal up to 30mg/mmol)
• HCV PCR 1 200.000
Investigations 2

15. A: conservative
B:dialysis
C: CST
D: Renal biopsy
o trial of iv diurtics
o Symptomatic treatment for uremic symptoms and oral
bicarbonate Na supplementation
o Antibiotics for UTI and chest infection
o Liver support with follow up liver function
Management

16. A: conservative
B:dialysis
C: CST
D: Renal biopsy
Management
On laboratory and clinical bases
Management

17. A: conservative
B:dialysis
C: CST
D: Renal biopsy
ManagementProteinuria,
drug history ,
no improvement on
conservative
treatment?
Leukocytosis
,CRP: 96
Diagnosis not confirmed
by renal biopsy yet

19. A: conservative
B:dialysis
C: CST
D: Renal biopsy
Management
Prepare the patient for biopsy as soon as possible:
 Control BP
 Adjust bleeding profile
 Treatment of infection
Management

20. • after 4 days of conservative ttt Patient clinically improved at
the level of liver function and leukocytosis ,but on the
other hand at the level of kidney function patient didn’t
show improvement either at the level of clinical condition ,
uop or. Laboratory investigation :
o S.creatinine 9.5 mg/dl
o PH: 7.3
o H2CO3:14
o PCO2: 23
o K: 6.3mmol/L
Patient kept on conservative measures ,start
steroids 3o mg/day , biopsy done and patient
started hemodialysis
Management

21. Biopsy result
• Mild focal mesangial proliferative
glomerulonephritis
• Focal interstital nephritis with eosinophils
infiltrate
• Focal fibrosis < 25 %
• Acute tubular injury
Biobsy Results

22. Biopsy result …cont
• Biopsy show 20 glomeruli /section
• Glomeruli show focal proliferation ,no thickening of basement membrane ,one glomeruli is totally sclerotic
• Tubules :acute tubular injury with occasional intratubular calcification
• Interstitium :focal inflammatory infiltrate with some eosinophils , focal fibrosis >25 %
• Blood vessels :unremarkable

23. Follow upDialysis and steroidsconservative
7/53/51/529/427/425/424/422/421/4Lab
&uop
2.43.75.25.56.17.59.58.98.2s,creat
mg/dl
3.74.244.75.256.36.45.9S.K
m.m/l
310024001800900650300200100250Uop:
ml/24
hr

24. Finally
• Patient diagnosed as acute interstitial
nephrites and mesangioproliferative GN and
discharged on serum creat: 1.5mg/dl and on
treatment steroids 30 mg/day,and after 2
weeks on fllow up
s.creat 0.9 mg/dl
And adviced to receive HCV treatment
Finally

25. Thank you