U06-12318#605635810

71 yo male,ARF (cr~300)RBC casts ++%g/day proteinuriaPANCA +ve

U06-12318

70 yo M admitted to CTU medicine (June 13) with confusion, ARF (sCr 285), anorexia, wt loss, weaknessPMhx: Htn, dyslipidemia, COPD (80 py smoker), DHS R hip ?osteoporosis, ?Etoh abuse. No documented renal disease.HPI 2 months ago: Visiting BC: picked up by police for driving erratically: admitted to hospital with delirium NYD, treated with risperidone: d/c after 1 week. sCr 170 (May, 2005: sCr=99). No documentation / discharge history availableJune 12: UAH ER: 1 mo history of anorexia, weakness, poor coordination, tremor, confusion. (Poor historian – separated from wife, few family) Meds: Risperidone, ASA, Coversyl 4mg OD. Physical Exam:183/84, AFib 180 NSR 80 with fluid. Afebrile. Wasted: 47 kg. Disoriented x 3, agitated, resting tremor. No focal neuro signs.Clinically dry: dry MM, flat JVP, no edema. PPP. Lungs clear. No active joints, rashes, lymphadenopathy, bruits. 

Initial InvestigationssCr 287, urea 40. U/A: 3+ protein, prot/Cr=469 mg/mmol, 26-50 RBC, occ WBC, occ hyaline casts.Urine C+S: no growthNa=153, K/TCO2/Cl N. sAlbumin=19, Ca=1.73, Po4=1.63, Mg N. LFTs, NH3, CK N.CBC: Hb 138 (MCV 95), Plt 159, WBC 6.1. Smear: no schistos, no hyperseg PMNs Renal U/S: N sized kidneys, increased echogenicity. No masses/hydro. Course in Hospital-Admitted to CTU with confusion ?EtOH withdrawal, ARF, hypovolemia, AFib. -Supportive care: IV crystalloid, benzos-sCr: 284 (6/12) 316 (6/13) 315 (6/14)-Nephro consult (6/15): suspected pre-renal ARF with underlying intrarenal process. Too combative for biopsy: repeat urine studies and serology-SPEP/UPEP –ve for M-band, C3 0.73 (N 0.8-2.0), C4 N, anti-GBM negative -

June 20: pANCA +ve, cANCA –ve, ANA+, dsDNA –ve Urine microscopy: ++RBC casts and heme-granular casts Minimal improvement in mental status CT head: non-acute ischemic lesions L frontal lobe and peri-ventricular white matter -June 21 (Wednesday): RENAL BIOPSY (after sedation) 

June15 June16 June17 June18 June19 June20

scr 316 313 296 289 299 285

Diagnosis:Renal Biopsy:Arteritis with fibrinoid change and medium sizedarteries with consequent tubular damage andmembranoproliferative glomerulonephritis withoccasional crescent formation.