1. Nephrology Pathology Rounds Oct 21/05

2. Clinical History
44 year-old male.  Presented in Spring 2005 with Cr 190 and protein > 4g/day 
Cr: July ; Sep with 1.8g protein/day; July ; October with 4.6g protein/day
Past Medical history: type 2 DM x 15 years with retinopathy (very poor glycemic control); htn, dyslipidemia, PVD, Hepatitis C, smoker, minimal ETOH
No history of NSAID use, herbal remedies, gout, rheumatologic diseases.
Medications: metoprolol, teveten, metformin, hydrochlorothiazide, lipitor, renedil, s/c insulin

3. Clinical History
Examination: volume overloaded, hypertensive, decreased peripheral pulses, nil else.
Investigations: U/S - normal size kidneys with subtle increase in cortical echogenicity; U/A - 3+ ptn, 2-3+ RBC;
Normal serology including C3, C4, ANA, ANCA, anti-DS DNA, immunoglobulins ( except borderline increase in IgG), and cryoglobulins

4. Immunofluorescence
IgG – Mild linear GBM staining – a common finding in diabetes
IgA – Trivial to mild mesangial staining
IgM – Moderate mesangial staining
C3 – Moderate vascular staining
C1q – Mild mesangial staining
Kappa – Negative
Lambda – Negative
Fibrinogen – Mild interstitial staining
Albumin – Moderate linear GBM and TBM staining

5. IgG

6. IgA

7. IgM

8. C3

9. Clq

10. Fibrin

11. Albumin

12. Albumin

13. Electron Microscopy

16. Diagnosis
Focal Proliferative Immune Complex Glomerulonephritis superimposed in an early Diffuse Diabetic Nephropathy