CASE 32 (October 2008)
Male patient, at 19-year-old he presented malaise, progressive edema, and decreased urinary volume. Proteinuria 12.1 g/24h, serum creatinine 2.0 mg/dL, microscopic hematuria. Normal serum complement levels. ANAs and ANCAs negative. Tests for viral hepatitis negative. Hyperlipidemia and hypoalbuminemia. A renal biopsy was undertaken (Figures 1 and 2).
He was treated with steroids without response; he also received cyclosporine, but nephrotic syndrome continued. Serum creatinine remained in values near to 2 mg/dL, but after 4 years post-biopsy it progressively increased until end-stage renal failure at 25-year-old. After 8 months in dialysis the patient received a cadaveric donor kidney. The kidney function was well in the first weeks. Immunosuppression: prednisone, cyclosporine, mycophenolate.
Seven days after transplantation he had proteinuria: 500 mg/dL. Proteinuria continues progressively increasing, and 3 months after he presents generalized edema and proteinuria 6.6 g/24h. Microhematuria; serum creatinine: 1.3 mg/dL; no other symptoms. Tests for B and C hepatitis: negative. No other alterations.
A renal biopsy was undertaken (Figures 3-8).
Figure 1. First biopsy. H&E; left, X200; right, X400.
Figure 2. First biopsy. Methenamine-silver stain; left, X400; right, X1,000.
Figure 3. Second biopsy (post-transplantation). H&E; left, X200; right, X400.
Figure 4.Second biopsy (post-transplantation). Left: Masson's trichrome, X400; right: PAS stain, X400.
Figure 5. Second biopsy (post-transplantation). Methenamine-silver stain, X400.
Figure 6. Second biopsy (post-transplantation). Direct immunofluorescence using antiserum to IgA, X400.
Figure 7. Second biopsy (post-transplantation). Direct immunofluorescence using antiserum to IgG, X400.
Figure 8. Second biopsy (post-transplantation). Direct immunofluorescence using antiserum to C1q, X400.
Direct immunofluorescence for IgM and C3: traces in capillary walls, with similar appearance to the image displayed for C1q.
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