1. 204060810 U06-5523 DM with microhematuria

2. U06-552344 yr married female,mother of two children, referred to the Renal clinic by family physician on january 27,2006 for investigation of protienuria with IDDM H/O Diabetes- Dx 1990-Gestational Age 29 Type 2- 7 years IDDM—4 years Having laser treatment for retinopathy-partial blindness Left eye—2 years Patient has no urinary symptoms Depressed-recent death of her mother Presenting features: 1.Hypertension-143/83 on Rx with ARB/HCTZ 2.Poorly controlled diabetes- HbAIc 9% 3.Urine analysis-protein,blood and red cell cast 4.Nephrotic range proteinuria (7gm/24hr) 5.Serum creatinine-166umol/L 6.GFR-31ml/min/1.73m2(MDRD) 7.C3/C4-normal 8.Quantitive Ig-IgG,IgA and IgM-normal 9.ANA-negative 10.U/S abdomen-normal kidneys

3. Other medical conditions: 1.hyperlipidaemia 2.hypothyroidism 3.anemia-normochromic,normocytic 4.Migraine headache Past Health: Diabetes diagnosed with pregnancy age 29-1990:Scr 57umol/L 1997-Scr 70umol/L- no proteinuria 2002-Scr 70umol/L-no proteinuria Renal diagnosis: 1. Chronic Kidney disease-Stage3 2. Nephrotic range of proteinuria + Hematuria ? Diabetic nephropathy with other parenchymal renal disease Plan: Investigate- renal biopsy U06-5523

4. IgG-moderate background IgA- minimal but definite granular mesangial in several segments of the non-sclerotic glomerulus. IgM- trace mesangial,close to negative C3- moderate to strong vascular and Bowman’s capsule near the vascular pole,with a few tiny mesangial granules C1q-negative Kappa-moderate basement membrane background with a few mesangial granules of doubtful significance Lambda-same as kappa Fibrin- moderate interstitial staining Albumin- moderate to strong basement membrane background IF

5. IgA

6. C3

7. Kappa

8. Lambda

9. Fibrin

10. Albumin

15. Comment: As well as the obvious diabetic nephropathy, the IF supports the presence of a small amount of mesangial IgA deposition,and the EM although indeterminate is at least consistent. The picture indicates a component of IgA nephropathy, but the advanced diabetic changes are by far the predominant process here.

16. Diagnosis: Renal Biopsy: Advanced Diabetic Nephropathy. Superimposed focal proliferative Glomerulonephritis on the basis of IgA Nephropathy.