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Upstate Medical university Case Study

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A 49 year-old man is referred because of persistent leg edema. He had sudden onset (“almost overnight”) swelling in the legs about 8 months ago and since then has gained 30 pounds. The past history includes a melanoma which was surgically resected 3 years earlier and recently diagnosed hypertension controlled with lisinopril. Review of systems and physical exam are negative except for edema. Blood pressure is 132/72 mm Hg; weight is 210 pounds.

Labs: hemoglobin 14.5 g/dl; serum creatinine 0.8 mg/dl; BUN 13 mg/dl; calcium 8.2 mg/dl; cholesterol 275 mg/dl (LDL 159; HDL 36); triglycerides 432 mg/dl; serum albumin 2.4 g/dl.

Serology (ANA, RF, RPR, ASO, HBV, HCV) all negative. Complement normal.

Urinalysis shows 3+ protein and 1+ blood. A 24 hour urine collection contained 5.6 g of protein.

1. Characterize the renal presentation (select from List 1).

2-4. What are the three (3) most likely diagnoses at this point? (select from either List 2 or List 3)

A renal biopsy was performed.

Pathology Report for Biopsy

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Renal biopsy shows renal cortex with 50 glomeruli represented.  A few are globally sclerotic (< 5%). The remainder are like those seen in figures 1 (H&E) and 2 (Jones silver). There is mild interstitial fibrosis and arterio-nephrosclerosis. Immunofluorescence is shown in figures 3 and 4.  Electron microscopy shows some capillary loops like those in figure 5 and some like those in figure 6.

5. What is the pathologic diagnosis? (select from List 2).