Page 967 - Clinical Immunology_ Principles and Practice ( PDFDrive )

CHaPter 68 Immunological Renal Diseases 933.e1

MUL t IPL e -CHOIC e QU e S t IO n S

1. A 45-year-old woman presented to the emergency department was afebrile, and his blood pressure was 140/80 mm Hg. The
(ED) with swelling in both ankles, 15-lb weight gain over the catheter site was clean, and the remainder of the examination
past 3 months and shortness of breath. During a physical was unremarkable. There was trace edema. Laboratory findings
examination 1 year prior, 1+ protein was noted on dipstick were notable for mild hypoalbuminemia (serum albumin of
urinalysis, but no further workup was done. There was no 3.1 g/dL), serum creatinine of 2.1 mg/dL, hypocomplement-
family history of renal disease. The patient has blood pressure emia (C3, 4 mg/dL, C4, 5 mg/dL, and CH50, 10 U/mL).
of 120/80 mm Hg, elevated respiratory rate of 25, and oxygen Urinalysis was notable for proteinuria 2+, and urine microscopy
saturation of 90%. Physical examination was notable for pitting revealed 15 acanthocytes per high-power field. The spot urine
edema in her legs up to the mid-thighs. Lungs were clear. protein/creatinine ratio was 1.8 g/g. Human immunodeficiency
Laboratory testing revealed a hemoglobin level of 14 g/dL, virus (HIV), antinuclear antibody (ANA), and hepatitis B
hematocrit of 42%, serum creatinine level of 1.0 mg/dL, blood and C screen results were negative. Renal biopsy was performed
urea nitrogen (BUN) of 28 mg/dL, albumin level of 1.6 g/ after admission. Light microscopy (LM) revealed diffuse
dL, serum total cholesterol level of 350 mg/dL (normal, mesangial and endocapillary hypercellularity, lobulation in
<200 mg/dL), and serum triglyceride level of 800 mg/dL the glomeruli, and double contours in the glomerular capillary.
(normal, <150 mg/dL). Serum complement levels were within Two of 18 glomeruli had segmental crescents. Immunofluo-
normal limits. Urinalysis demonstrated 4+ protein on dipstick. rescence microscopy revealed staining for IgG (3+) and C3
Urine microscopy revealed 0–2 nondysmorphic red blood (3+) along the capillary and mesangial regions in a granular
cells per high-power field, oval fat bodies, and fatty casts. A pattern. Electron microscopy (EM) revealed subendothelial
spot protein/creatinine ratio was 8 g/g. The chest radiography and mesangial electron-dense deposits. What further workup
result was negative. Computed tomography (CT) angiography is indicated?
revealed multiple pulmonary emboli, and therapeutic anti- A. ANCAs testing
coagulation was immediately initiated. Renal biopsy was B. Anti–glomerular basement membrane (GBM) antibody
deferred because of the need for urgent anticoagulation. What C. Blood culture
would have been the most likely biopsy finding if biopsy had D. Evaluation for genetic mutations of complement regulatory
been done? proteins, including complement factor H (CFH), CFI, and
A. Acute post infectious glomerulonephritis Membrane cofactor protein (MCP).
B. Alport syndrome 3. A 60-year-old male with new diagnosis of Hodgkin lymphoma
C. Antineutrophil cytoplasmic antibodies (ANCAs)–associated was noted to have 3+ edema on examination by his oncologist.
crescentic glomerulonephritis Serum creatinine was 1.1 mg/dL. Serum albumin was 2.5 g/
D. Membranous nephropathy (MN)
dL. Urinary protein excretion revealed 6 g/24 hr. Urine
2. A 20-year-old male with history of short bowel syndrome microscopy showed fatty casts but no cellular elements. Kidney
was admitted to the hospital with elevated creatinine, mac- biopsy result was consistent with minimal change disease
roscopic hematuria and proteinuria, and renal insufficiency. (MCD). What is the appropriate treatment?
He had been on long-term peripheral nutrition via a central A. High-dose prednisone
venous catheter for 4 years. He was admitted 6 months ago B. Cyclosporine with prednisone
with a line infection and was given antibiotics for 7 days, but C. Mycophenolate mofetil
the line was not removed. He was noted to have trace pro- D. Chemotherapy
teinuria and hematuria 6 months ago. Upon admission, he