U06-23362

#944696920

• ATN 1 year ago with recovery but now proteinuria with DM

• ?other diagnoses

• 49y Aboriginal male with DM dxd in 1989 and HT dxd in 2003• Several admissions to ER with high creatinines which then resolved,

? From volume depletion/ACE inhibition, elevated CKs• Creatinine oscillating• High grade proteinuria, 3+ since at least 2004, PCR of 707 on July

2006.• HbA1c 10.1 in 2004, 7.2 in Nov 2006• UA –tr- 1+ blood, 3+ protein, some dysmorphic rbc, no rbc casts,

some granular casts• C3, C4 normal, ANA, ANCA, anti GBM, SPEP, Hep B, Hep C

negative• Albumin 27, Cholesterol 7.14 → CK of 900 on lipitor!• Renal US – normal kidneys• BP shot up in October, requiring 4-6 meds for control, c/o puffy face

and periodic pedal edema• MRA – no renal artery stenosis

Creatinine

Urine PCR

ER, ? dehydration

ER, ? dehydration

Renal clinic

BP 121/72

BP 146/87

BP 194/107

BP 116/86

BP 117/80

IF• IgG- Mild linear GBM staining, a common finding in diabetes.• IgA- Mild to moderate mesangial staining. • IgM- Mild mesangial staining. Mild vascular staining. • C3- Mild to moderate mesangial staining. Moderate vascular

staining. • C1q- Moderate mesangial staining. Moderate vascular staining. • Kappa and Lambda- Negative.• Fibrinogen- Mild interstitial staining. • Albumin- Mild to moderate linear GBM and TBM staining, a

common finding in diabetes. Moderate hyaline droplet change in tubular cytoplasm.

IgG

IgA

IgM

IgM

C3

C3

C1q

C1q

fibrinogen

albumin

albumin

albumin

EM

• Will be ready in the coming weeks

DiagnosisRenal Biopsy:• Diffuse diabetic glomerulosclerosis with

superimposed focal proliferative IgA nephropathy with occasional crescent formation.