Case Conference 신장내과 R2 최소영

조 O 순 (F/71) adm : C.C) Evaluation of proteinuria P.I ) 10 년전 DM, HTN 진단 투약중인 자로 발생한 Left side weakness 와 dysarthria 로 경희 한방병원 입원, acute cerebral infarction 에 대해 manage 받고 호전되었으 나 검사상 hypoalbuminemia 와 proteinuria 발견되어 futher evaluation 위해 신장내과로 전원됨 PMHx) DM /HTN/ TB / Hepatitis (+/+/-/-) Op Hx (-) Personal Hx) Alcohol / Smoking (-/-)

Review of Systems General fatigue(-) fever(-) chill(-) Wt. gain(-) Skin rash(-) pigmentation(-) E & ENT visual disturbance(-) diplopia(-) nasal obstruction(-) Respiratory cough(-) sputum(-) hemoptysis(-) dyspnea(-) cyanosis(-) Cardiac angina(-) orthopnea(-) palpitation(-) dyspnea(-) exertional dyspnea(-) G-I A/N/V/D/C (-/-/-/-/-) abdominal pain (-) melena(-) hematochezia(-) Renal oligurina(-) dysuria(-) hematuria(-) incontinence(-) both flank pain(-) urgency(-) fequency(-) residual urine sensation(-)

Physical Examination V/S 150/90 mmHg – 88/min – 20/min – 36.7 ℃ B.W) 58kg Height) 152cm BMI) 25.1kg/m2 General Alert consciousness Not so ill appearance Skin No rash, No pigmentation Head & neck No Neck vein Engorgement Eyes/ENT Isocoric pupil with PLR(++/++) Slinghtly pale conjunctivae Clear sclerae Chest Clear breathing sound without crackle Regular heart beat without murmur Abdomen Soft and flat abdomen No tenderness or rebound tenderness Normoactive bowel sound No hepatosplenomegaly Back/extremity CVA tenderness(-/-) Pretibial pitting edema(+/+)

Initial Laboratory Finding CBC/DC 6080/mm g/dL –25.9% - 341X10 3 / ㎣ (Seg %) MCV 99.3 fL, MCH33.4 pg Chemistry TB/DB 0.48/0.19 mg/dL AST/ALT 20/9 IU/L ALP/GGT 32/10 IU/L Prot/Alb 4.3/2.5 g/dL LD/CK 668/53 U/L Glucose 138 mg/dL Ca/P/Mg 8.4/4.3/2.5 mg/dL Uric acid 3.9 mg/dL BUN/Cr 3/0.8 mg/dL Na/K/Cl 142/3.4/109 mmol/L UA RBC 0~1/HPF WBC 0-1/HPF O.B.:2+ Ketone(-) Glucose(-) Protein >300 SG: pH: 5.5

Lipid profile Total cholesterol : 125 mg/dL Trigalyceride : 96 mg/dL LDL-cholesterol : 76 mg/dL HDL-cholesterol : 30 mg/dL Viral marker HBsAg/HBsAb/HBcAb (-/+/-) Anti-HCV (-)

Chest PA

ECG

Problem list 1. Proteinuria, hypoalbuminemia 2. DM 3. Anemia 4. Hypertension 5. Cerebral infarction

Initial Assessment Diabetic nephropathy r/o nephrotic syndrome d/t other cause Type 2 DM Macrocytic Anemia Hypertension Cerebral infarction

Initial Plan 1. 24hr urine collection renal biopsy Serologic markers (IgA, C3, C4, RF, ANA, RF, ASO) abd.sono 2. DM complication study 3. Anemia study(serum Iron, TIBC, ferritin, Vitamin B12, Folate)

Laboratory Finding 24hr urine collection Protein 12320mg/day Creatinine 827 mg/day Urine volume 1120 mL/day CrCl 57.4 mL/min RF:<20 IU/ml (<20)IgA: 179 mg/ml (68~378) C3: 76 mg/dl (88~201)C4: 24 mg/dl (15~45) ANA: (-)ASO: <58 IU/ml Autonomic function test: autonomic score 7 →definite involve Fundoscopy: wihtin normal range →no retinopathy Serum iron :46ug/dl (50~150)TIBC : 143ug/dl (200~400) Ferritin : 68ng/dl (15~332) Vitamine B12 : 0.3pg/dl (160~970)Folate: 8.2 ng/dl (>1.5)

Renal Biopsy

Gastroscopy

Clinical Course Anti-gastric parietal ab: weakly positive Anti-Intrinsic factor ab: detected →pernicious anemia →cobalamine replacement Renal biopsy 후 discharge & OPD f/u →methlprednisolone & cyclophosphamide

Final diagnosis Membranoproliferative glomerulonephritis, type I Pernicious anemia d/t chronic atrophic gastritis