Chronic Glomerulonephritis
Short Summary

42-year-old female with chronic renal insufficiency secondary to immune complex mediated glomerulonephropathy, hypertension, Type 2 diabetes mellitus, and hyperlipidemia. The recommended solution for her is kidney transplant. Possible causes of immune complex deposition disease include Cryoglobulinemia, IgA nephropathy, Membranous nephropathy, and Idiopathic immune complex mediated glomerulonephritis which is the diagnosis of exclusion.

Patient's Questions
1)    Any further diagnostic tests that could lead to better treatment ?
2)    Any suggestion for conservative therapy
3)    Is it time for kidney transplant or is it better to wait until there is further renal deterioration?
Her main question is whether to try to go for an immediate kidney transplant or wait for further deterioration in renal function.
Medical Background

Feb-09
42 years old, a mother of 4 children, Israel
Diagnosis:
Chronic Glomerulonephritis (per biopsy 1/2009)
Chronic Renal failure
Diabetes type II – No Target Organ Disease
Obesity (BMI>30)
Gastric Band
Hypercholesterolemia
Blood type O+
The patient has chronic renal failure as of 2007. Urea 197. CCT/MDRD 18ml/min.
On January 2007 a kidney biopsy have demonstrated chronic glomerulonephritis with immune-complexes.
Currently, her physicians recommend a preemptive renal transplant.

Results of Tissue Typing
Auto Ab- Negative
Class I : serology - 2/2009
Class II : SSOP - 2/2009
HLA-A3    Cw4     B35 (Bw6)
 
 
May-09
 
According to our files the patient height is 1.71 meters and weighs 87 kilos.
Accordingly her BMI is 29.75.
She is making efforts to lose more weight.
 
Aug-09
Currently her BMI is 29.8
Her other medical conditions include:
-       Obesity
-       Cholelithiasis
-       S/P gastric band
We also know that the patient has:
1. Stage 4-5 renal insufficiency
2. Significant anemia
3. Hyperparathyroidism and the patient is on appropriate therapy for these conditions.
Other Laboratory results include:
1. ASLO titre     445 IU/ml (0-200)             
2. Hep B and Hep C Negative
3. HIV Negative
4. ANA and lupus serologies Negative
5. Cryoglobulin (should be checked)

Expert's Opinion

We do not know what the presenting symptoms were but the patient had a renal biopsy done on January 2009. The diagnosis is that of chronic glomerulonephritis with immune complex deposition. Some of the information we would like to have are not reported (light chain, kappa and lamda light chain) but we do know that 5/18 glomeruli are globally sclerosed. 13 had open capillaries and some of these have thickened Bowman's capsule.
The cause of the immune complex deposition disease is unclear from the data available. Possible causes include:
1. Post-infectious glomerulonephritis (including post-strep glomerulonephritis, hepatitis B, hepatitis C and HIV); all are ruled out by the tests indicated although ASLO titer is indeed elevated
2. Lupus nephritis is ruled out with the negative ANA and negative serologies
3. Cryoglobulinemia is still a possibility
4. IgA nephropathy is still a consideration
5. Membranous nephropathy is less likely with the included information
6. Idiopathic immune complex mediated glomerulonephritis is obviously the diagnosis of exclusion
The specific question that was asked was that of the timing of the transplant. The interesting observation is that the patient's renal function appears to be getting better from the February data set to the March data set. Since patients with post-infectious GN and inflammatory GN (such as lupus) can indeed improve after the acute flare, it would be prudent to continue to manage medically. Anti-hypertensive agents, Mimpara, Erythropoeitin and Venofen should be continued. Although the renal biopsy does show scaring with tubular atrophy and interstitial fibrosis, it is possible for the creatinine to settle in the 1.8 range.
Over time, however, the renal function may gradually progress to needing transplantation at a future date.
With respect to transplantation:
1. It would be important to identify any potential donor since we do have time to optimize this situation.
2. The patient should continue to try and optimize her body weight since steroid administration after the transplant can significantly aggravate the weight issue.
I would be happy to provide additional help depending upon the further characterization of the immune complex mediated GN.

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