1. U05-19226

2. Clinical History ID - 94 yo M PMHx – remote IHD with CABG in 1980. HTN. Active and living independently prior to presentation Sept 22/05 at Panoka Hospital. Baseline Cr 100 June 2005 Sept 22/05- admitted with GI complaints – hydrated, but then actively diuresed. Treated with 3 antibiotics: Biaxen, Cefazolin and Cipro. On ACEI. First elevated urea Sept 29 at 30.7, with Cr 533 Oct 1. Oliguiric with no further response to high dose Fureosemide. Transferred to UAH Oct 4 with Cr 819 with elevated K and fluid overloaded. Dialysis initiated Oct 7. Progressively anuric until last 5 days when urine output increased in response to diuretic challenge.

3. Investigations: U/A - +1 ptn, +3 hgb, 2+ leuks. ++WBC and RBC. No eosinophils Hgb 85 PTH 42. Ca 1.58 PO4 3.18. Alb 29 Serologies negative. Normal compliments. CRP 70 24hr urine for protein 1.9 g/l. SPEP negative. Urine PEP – Kappa Chains Skeletal survey negative BM Bx – 14% plasma cells

4. LM

5. IF IgG, IgM, IgA: negative C3 : moderate punctate mesangial staining C1q negative Kappa: strong hyaline changes in tubular cytoplasm Lambda : negative Fibrin : moderate interstitial staining Albumin : negative

6. C3

8. Kappa

9. Fibrin

10. Diagnosis Light chain cast nephropathy with tubular injury consistent with kappa light chain disease