A 32 year old man presents wtih 3 days of vomiting, nausea, and malaise. HIV was diagnosed 6 months ago but he has not been started on ant-retroviral therapy. He has no other significant past medical history.
He is apyrexial. BP is 100/60 and pulse 82. He has no oedema. JVP is not visible when lying flat.
Urine dipstick shows 1+ protein only. The only other investigation available is serum creatinine – 700 micromol/l (8 mg/dl).
What do you think are the main diagnostic possibilities here? What additional key questions would you like to ask? What would your initial management be?
Write what you think and what you'd do
Case contributed by Fran Th’Ng and Gavin Dreyer
A 15 year girl presents to Queen Elizabeth Hospital Blantyre with a one-month history of facial oedema. It is worse in the morning, slightly better at night and not associated with shortness of breath or cough. She has been well recently, with no intercurrent illnesses. She has never had any body swelling until noticing swelling of her feet in the last week or two. On further questioning, 6 months ago she probably had an episode of macroscopic haematuria. She has not reached menarche. She lives in Nkhotakota.
On examination she is slim but has marked bilateral pitting pedal oedema and facial puffiness; she probably also has ascites. She is apyrexial. General examination is unremarkable. Her BP is 110/60, pulse 72. She has reduced breath sounds and dullness to percussion at both lung bases. Heart sounds and abdomen are normal and she has no neurological deficit.
A urine dipstick shows 4+ protein, 3+ blood. She has a serum creatinine of 60 micromol/l (0.7 mg/dl) and a normal blood count. Tests of liver function, serum proteins are not available.
- What is the differential diagnosis at this stage?
- Further immunological tests are not possible, nor is a renal biopsy, but what simple tests are essential to your management?
Write what you think and what you'd do
Show the answer?
The urine dipstick findings are strongly suggestive of ‘nephritic’ type glomerulonephritis. In this region, post-infectious glomerulonephritis is the most likely cause, though the history here is long, and she is not hypertensive. Other causes are certainly possible. However …
Urine microscopy is a key test in a patient with suspected glomerulonephritis. In her case it showed red cells, but these were of normal shape, and no casts were seen. However Schistosoma haematobium ova were seen.
Schistosomiasis is endemic around Lake Malawi. A positive dipstick test for blood would usually be taken to indicate current infection. Serology for Schistosoma antibodies is of no value as previous exposure is usual.
This complicates interpretation and management significantly. Given that her creatinine and blood pressure were normal, she was treated for Schistosomiasis and reviewed one month later. At that review she is still oedematous and urine dipstick shows 4+ protein. Now what do you think?
Read more in A 16 year old girl with oedema
Case contributed by Fran Th’ng and Gavin Dreyer
Dear Doctor, this 73 year old gentleman had been awaiting a knee operation, but this was cancelled as a result of pre-operative blood tests revealing altered renal function. We repeated these tests and these show U 7.2, Cr 185 and eGFR 31. He also had a macrocytic anaemia, and a GGT of 239. He admits to drinking more than he should. His dipstick tested positive for protein and glucose, and he is currently awaiting a GTT as his random glucose was 9.8. We unfortunately have no records of previous blood tests.
He keeps well, otherwise, and his only relevant previous history is osteoarthritis.
We have organised repeat U&E, B12/folate, Ca and PO4, GTT, and urine sample for protein:creatinine ratio. I have also organised a renal ultrasound. I would be grateful for any further advice, or other investigations we should be performing at this stage.
What further information would you seek before giving your opinion?
See more history, results?
Unfortunately we couldn’t find any historic blood test results either. So we asked what drugs he was taking:
- Co-Codamol 8mg/500mg tabs 1 or 2 tabs every 4 to 6 hours as required
Now consider which one of these three options to go for: (1) Give Advice, (2) See in Outpatients non-urgently, or (3) Send this patient to us now!
Now read what the expert wrote
His eGFR of 31 keeps him (just) in Stage 3 CKD rather than 4. Most likely he has had renal impairment for some time and this is fairly stable, but the proteinuria result will be relevant. At stage 3 CKD the triggers for referral are officially PCR >100, or deteriorating function, or proteinuria plus haematuria. These because they highlight patients at increased risk of deterioration.
Hope that is helpful, let us know if you’ve any more Qs.
Other points left unsaid: there isn’t really a great reason for doing any renal imaging in this gentleman if he has no urinary symptoms, and his figures are stable. We didn’t comment on his drugs because he isn’t on anything nephrotoxic. The codeine in co-codamol isn’t usually enough to accumulate symptomatically at this level of renal function.
Go to the Advice Line page, where things are sorted by complexity and subtopic, or take a lucky dip from the cases below
Things to read:
(Put reference sources here)