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Chapter 27: Membranous Nephropathy

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A 65-year-old man, with a past history of hypertension controlled on amlodipine, presented to the ER with bilateral lower limb swelling for the past 10 days. He has a 30-year history of smoking 1 pack per day but quit 5 years ago. On review he mentions increased frothiness in his urine. His physical examination reveals a blood pressure of 140/90 mm Hg, and a heart rate of 80 beats/min. He has bilateral lower limb swelling extending to the thighs. He weighs 80 kg compared to a baseline of 75 kg 3 months ago. Cardiovascular examination shows normal heart sounds. His chest is clear to auscultation. The rest of his examination is unremarkable. On laboratory investigations, his serum creatinine is 1.7 mg/dL, 24-hour urine protein is 10 g/day. Serum albumin is 11 g/L, hemoglobin 123 g/L. His kidney biopsy shows features of membranous nephropathy, with GBM thickening on light microscopy and by IF, IgG and C3 deposition in a granular fashion was seen and confirmed by subepithelial electron dense deposits on EM. His glomerular tissue staining for PLA2R is positive.

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Which of the following steps in management should NOT be introduced at this time?

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A. Add ramipril 5 mg once daily.

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B. Start cyclosporine 125 mg twice daily.

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C. Begin anticoagulation for venous thromboembolism prophylaxis.

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D. Obtain CT chest to rule out lung cancer.

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The answer is B. The patient has newly diagnosed MN. Although he is anti-PLA2R positive, the long history of smoking makes it imperative that lung cancer is rule out by performing a chest CT. He is hypertensive and thus should be started on angiotensin II blockade, which may also reduce proteinuria. The fact that he is severely nephrotic with a serum albumin of 11 g/L raises consideration for anticoagulation prophylaxis, unless contraindicated. We do not have information on serum anti-PLA2R levels and they are crucial in ascertaining probability for spontaneous remission and to guide introduction of immunosuppression (De Vriese, et al. J Am Soc Nephrol. 2017;28(2):421–430). As such, initial therapy in this case should be maximizing conservative therapy with low-sodium and low-protein diet, angiotensin II blockade and blood pressure control.

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A 32-year-old woman, presents to the emergency department complaining of bilateral lower limb swelling for 1 week. Her past medical history and review of systems is unremarkable. On physical examination, she has bilateral lower limb swelling extending to the knees. Her blood pressure is 130/65 mm Hg, heart rate is 70 beats/min. Chest and cardiovascular examinations are unremarkable. Her laboratory investigations show, serum creatinine 0.7 mg/dL, serum albumin 10 g/L, Hb 121 g/L, platelets 202 × 10(9)/L, INR and APTT are normal. Urine PCR is ...

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