1/
She was a centenarian. She had hypertension her whole life. She was on a classic regimen.
She was a centenarian. She had hypertension her whole life. She was on a classic regimen.
2/
Over a period of months she developed severe LE edema, jugular venous distention, orthopnea, dyspnea, and recurrent transudative left-sided pleural effusion
Over a period of months she developed severe LE edema, jugular venous distention, orthopnea, dyspnea, and recurrent transudative left-sided pleural effusion
3/
Labs showed a Cr 3 from 0.6 months earlier, Hgb 6 from 10 months prior. BNP elevated.
Labs showed a Cr 3 from 0.6 months earlier, Hgb 6 from 10 months prior. BNP elevated.
4/
What can you confidently diagnose?
What can you confidently diagnose?
5/
HF is a clinical diagnosis. Can have NORMAL echo and HF. Can have ABnormal echo and NOT have HF. You don't trust the Cr as estimate of eGFR based on recent @COREIMpodcast episode b/c she is sarcopenic from aging and Cr likely to overestimate eGFR.
HF is a clinical diagnosis. Can have NORMAL echo and HF. Can have ABnormal echo and NOT have HF. You don't trust the Cr as estimate of eGFR based on recent @COREIMpodcast episode b/c she is sarcopenic from aging and Cr likely to overestimate eGFR.
6/
Cystatin C suggests eGFR 10! There are 2 possibilities here. (1) HF leading to kidney injury, (2) Kidney injury unmasking HF (impaired fluid homeostasis impairs the vulnerable heart)
Cystatin C suggests eGFR 10! There are 2 possibilities here. (1) HF leading to kidney injury, (2) Kidney injury unmasking HF (impaired fluid homeostasis impairs the vulnerable heart)
7/
To test the 1st hypothesis you pursue lasix challenge test. You give 1mg/kg lasix IV and hope the kidney makes a strong stream of yellow urine. You know it must be a STRONG challenge b/c have only few functioning nephrons.
To test the 1st hypothesis you pursue lasix challenge test. You give 1mg/kg lasix IV and hope the kidney makes a strong stream of yellow urine. You know it must be a STRONG challenge b/c have only few functioning nephrons.
8/
@rabihmgeha stresses treatment is often ultimate diagnostic test. She makes no urine. eGFR continues to worsen. The 2nd hypothesis warrant consideration. You resend and re-evaluate the UA. There is albuminuria + hematuria.
@rabihmgeha stresses treatment is often ultimate diagnostic test. She makes no urine. eGFR continues to worsen. The 2nd hypothesis warrant consideration. You resend and re-evaluate the UA. There is albuminuria + hematuria.
9/
You remember @AaronLBerkowitz teaching you that vasculopathy is easy to dx but vasculitis is difficult. Here the albuminuria is diagnostic of glomerulopathy (it is high molecular weight protein and should not filter through intact glomerulus).
You remember @AaronLBerkowitz teaching you that vasculopathy is easy to dx but vasculitis is difficult. Here the albuminuria is diagnostic of glomerulopathy (it is high molecular weight protein and should not filter through intact glomerulus).
10/
You will review the urine but recognize it is NOT easy to see dysmorphic RBCs & casts. No matter what the frame of AKI + albuminuria + hematuria have prioritized a rapidly progressive glomerulonephritis. You are confident to go from glomerulopathy to glomerulonephritis
You will review the urine but recognize it is NOT easy to see dysmorphic RBCs & casts. No matter what the frame of AKI + albuminuria + hematuria have prioritized a rapidly progressive glomerulonephritis. You are confident to go from glomerulopathy to glomerulonephritis
11/
Why would such an old person suddenly develop GN? It must be triggered. You go back and review her meds. She was started on hydralazine a few months prior to this. You know it can cause an overlap of drug induced lupus and ANCA-associated vasculitis.
Why would such an old person suddenly develop GN? It must be triggered. You go back and review her meds. She was started on hydralazine a few months prior to this. You know it can cause an overlap of drug induced lupus and ANCA-associated vasculitis.
12/
The kidney involvement makes ANCA-associated vasculitis more likely. Labs confirm your hypothesis. Now you have to deplete Bcells w/ rituximab (anti-CD20) and give steroids. You are left wondering, do we really need to control BP closely in someone this old?
The kidney involvement makes ANCA-associated vasculitis more likely. Labs confirm your hypothesis. Now you have to deplete Bcells w/ rituximab (anti-CD20) and give steroids. You are left wondering, do we really need to control BP closely in someone this old?
13/
This was a case presented at morning report by my friend Alex. He taught us all this w/ one case. This is the POWER of morning report. Thank you, Alex.
This was a case presented at morning report by my friend Alex. He taught us all this w/ one case. This is the POWER of morning report. Thank you, Alex.
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