Renal Clinicopathologic Conferences at the
Columbia University Medical Center

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A 54-year-old male with skin rash and proteinuria
54-year-old white male with increasing proteinuria over 4 months. There is a history of diabetes for 1 yr, newly diagnosed hypertension. What is the differential diagnosis and how would you treat him? (Edited by Jai Radhakrishan, MD and Barry Stokes, MD).

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A 60-year-old male with chronic lymphocytic leukemia and nephrotic syndrome
Male with chronic lymphocytic leukemia with increasing proteinuria over 2.5 years, from 0.8 to 1.4 to 7.2 g/day. Serum creatinine is 1.3 mg/dL with negative serologies. What is the differential diagnosis and how would you treat him? (Edited by Jai Radhakrishan, MD and Barry Stokes, MD).

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A middle-aged Hispanic male with microhematuria and proteinuria
A middle-aged Hispanic male had with history of incarceration, occupation as a welder, heroin abuse, presented with proteinuria 3.4 g/day and microhematuria. No DM. Mild HTN. Normal sized kidneys. Negative serological tests. Initial DDx: Membranous, IgA, FSGS. Discussion focus: Hint: IgG deposits were found.

(Edited by Robert Isom, MD and Barry Stokes, MD).

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A middle-aged male with new onset nephrotic syndrome
A middle-aged male had hyperlipidemia, heavy smoking history, hypovitaminosis D, no DM, no HTN, no family history of renal disease. Taking furosemide, simvastatin, lisinopril, vitamin D. Presents with pedal edema and 13g/day proteinuria. Serum albumin is 2.2 g/dL. Complements and serologies are normal. Is it membranous GN? FSGS? Minimal change disease? Amyloidosis? Discussion focus: Thin basement nephropathy and membranous nephropathy.

(Edited by Jai Radhakrishnan, MD).

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A middle-aged male with primary biliary cirrhosis and renal insufficiency
A middle-aged male with primary biliary cirrhosis, nephrotic proteinuria, inactive urine sediment, low complement, renal insufficiency. Is it hepatic glomerulopathy, immune complex glomerulonephropathy, or membranous lupus? Teaching points: MGN is the most common glomerular disease in patients with PBC It is extremely rare (<10 cases). IF shows IgG, IgM, C1q. The pathogenesis is in situ immune formation (anti-mitochondrial globulins extracted from the subepithelial deposits? - evidence of common mechanism)

(Edited by Jai Radhakrishnan, MD).

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A woman in her 60's with uveitis and renal insufficiency
A Caucasian woman in her 60ís was referred with renal insufficiency (serum creatinine 1.8 mg/dL, unknown baseline). Headaches x 3 months. Past medical history: 18 months prior, she was diagnosed with uveitis, treated with ocular steroids. 6 months prior, diagnosed with hypertension; BP 185/105, scleral erythema, no edama, otherwise normal. Serum creatinine 1.8 mg/dl; Urine microscopy: 14 WBC/HPF, no RBC Urine protein: 277 mg/24 hours; Renal ultrasound: normal sized kidneys C3, C4 depressed, ESR 27, serologies negative. What is the differential diagnosis? Teaching points: The TINU syndrome consists of bilateral anterior uveitis and interstitial nephritis, and is a diagnosis of exclusion. It typically affects young females. The renal disease is usually self-limiting, but uveitis may recur.

(Edited by Jai Radhakrishnan, MD).

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A Vietnamese female in her 50ís with miliary tuberculosis and renal failure
A Vietnamese woman in her 50ís presented with a several-week history of liver dysfunction. She initially received treatment with steroids for possible auto-immune hepatitis, but later found to have hepatitis B infection. She subsequently diagnosed with miliary TB with lung involvement. Teaching points: Renal tuberculosis may present as part of generalized dissemination, or as a localized form. TB interstitial nephritis may be associated with renal impairment. Early cases may be treated successfully with anti-TB therapy. With late stages, surgical intervention may be necessary

(Edited by Jai Radhakrishnan, MD).

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A female in her 30ís with a renal transplant, diagnosed with BK nephropathy, came for a 2nd opinion.
What is the optimal way to diagnose this condition, how do we diagnose cellular rejection in the setting of BK nephropathy, what treatment options can we consider? Teaching points: BK virus nephropathy may be seen in up to 8% of renal transplants.
-The gold standard for diagnosis is the finding of inclusions in the renal biopsy which stain for the SV40 antigen.
-Surrogate markers include the finding of decoy cells and PCR for BK virus.
-Screening for BKN may lead to early diagnosis and potentially improved outcome.
-Treatment strategies include reduction of immunosuppression, and the possible use of leflunomide, cidofovir and sirolimus.

(Jai Radhakrishnan, MD, Editor).

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A Caucasian female in her 30's with acute renal failure and proteinuria after a renal transplant.
This patient originally had diagnosis of minimal change disease treated with steroids and later, cyclosporine and found to have FSGS. Within 12 months she had ESRD. After an LRD transplant, she had recurrence of FSGS. Teaching points: What is the recurrence rate of FSGS after transplant? Is use of a living donor acceptable? Is early treatment with plasmapheresis of benefit?
(Jai Radhakrishnan, MD, Editor).

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A 48 year old Black female with HIV/AIDS and worsening renal function with positive lupus serologies
48 year old Black female with HIV/AIDS since 1985, was evaluated for rising BUN and creatinine. ANA and dsDNA tests for lupus were positive. Teaching points: There is a significant overlap between clinical manifestations of SLE and HIV. Combined renal lesions of SLE & HIV are more frequent in Blacks, males, and children with perinatally acquired HIV. Most patients had HIV diagnosed before SLE and were hypocomplementemic. Treatment is challenging; most pts have received prednisone with varying results. Anti-retroviral treatment should be continued.
(Behzad Alimohammadi, MD; Sumit Mohan, MD; Herman Anderson, MD. Harlem Hospital Center).

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Acute Renal dysfunction and Hypophosphatemia after Renal transplant
A woman in her 40's was recently treated with steroids for rejection, presents again with a rising creatinine. Is this the usual case of rejection vs calcineurin toxicity? Teaching point: When and how do we get hypophosphatemia in renal transplant patients? When and how should this be treated?

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A woman in her 60s with a past history of lupus, presenting with renal insufficiency
A Caucasian woman in her 60s with remote history of lupus and a recent colonoscopy presents with renal insufficiency, subnephrotic proteinuria, and a benign urinary sediment. Her ANA is positive, but other serologies are negative. What is the differential diagnosis? Teaching point: How can one distinguish lupus nephropathy with APL antibody from primary APL nephropathy?

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Nephrotic Syndrome and Acute Renal Failure with Positive ANA
A woman in her seventies presents with edema and rising Scr and ANA 1:640. Is it lupus? Collapsing FSGS? MC or membranous with superimposed ATN, interstitial nephritis, or renal vein thrombosis?. Teaching point: What is the pathogenesis and DDx of ARF in nephrotic syndrome?

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The weekly renal clinicopathologic conference at CUMC is one of the premier teaching activities of the divisions of renal pathology and nephrology. The format of the conference is designed to foster academic discussion on diagnostic and treatment aspects of unusual and complicated nephrology patients. Initially, the clinical aspects of the case are presented by the nephrologist followed by a discussion about differential diagnoses among the audience members. The pathologist then discusses the findings on the renal biopsy followed by an in-depth review of the literature pertaining to the case. Follow up information on treatment and the subsequent clinical course is then presented.

The slides displayed in each presentation are designed to capture the essence of these conferences and will hopefully, provide a useful learning experience.