204060810U06-5523

DM with microhematuria

U06-552344 yr married female,mother of two children,referred to the Renal clinic by family physician on january 27,2006 for

investigation of protienuria with IDDM

H/O Diabetes- Dx 1990-Gestational Age 29 Type 2- 7 years IDDM—4 yearsHaving laser treatment for retinopathy-partial blindness Left eye—2 yearsPatient has no urinary symptomsDepressed-recent death of her motherPresenting features:1. Hypertension-143/83 on Rx with ARB/HCTZ2. Poorly controlled diabetes- HbAIc 9%3. Urine analysis-protein,blood and red cell cast4. Nephrotic range proteinuria (7gm/24hr)5. Serum creatinine-166umol/L6. GFR-31ml/min/1.73m2(MDRD)7. C3/C4-normal8. Quantitive Ig-IgG,IgA and IgM-normal9. ANA-negative10. U/S abdomen-normal kidneys

Other medical conditions:1.hyperlipidaemia2.hypothyroidism3.anemia-normochromic,normocytic4.Migraine headache

Past Health:Diabetes diagnosed with pregnancy age 29-1990:Scr 57umol/L1997-Scr 70umol/L- no proteinuria2002-Scr 70umol/L-no proteinuria

Renal diagnosis: 1. Chronic Kidney disease-Stage3 2. Nephrotic range of proteinuria + Hematuria ? Diabetic nephropathy with other parenchymal renal disease

Plan: Investigate- renal biopsy

U06-5523

• IgG-moderate background• IgA- minimal but definite granular mesangial in several

segments of the non-sclerotic glomerulus.• IgM- trace mesangial,close to negative• C3- moderate to strong vascular and Bowman’s capsule

near the vascular pole,with a few tiny mesangial granules• C1q-negative• Kappa-moderate basement membrane background with a

few mesangial granules of doubtful significance• Lambda-same as kappa• Fibrin- moderate interstitial staining• Albumin- moderate to strong basement membrane

background

IF

IgA

C3

Kappa

Lambda

Fibrin

Albumin

Comment:

As well as the obvious diabetic nephropathy, the IF supports the presence of a small amount of mesangial IgA deposition,and the EM although indeterminate is at least consistent. The picture indicates a component of IgA nephropathy, but

the advanced diabetic changes are by far the predominant process here.

Diagnosis:Renal Biopsy:Advanced Diabetic Nephropathy.Superimposed focal proliferative Glomerulonephritis on the basis of IgA Nephropathy.