1. 단백뇨 소견을 보인 27세 남자 환자
R3 박선희/Prof. 임천규

2. M/27. 만성 B형 간염 진단 받은 자로 02년도 고대 병원에서 단백뇨
김O태 (M/27) Adm:
Chief Complaint
Facial edema o/s) remote 3년 전
recent 한달 전
Present Illness
M/27. 만성 B형 간염 진단 받은 자로 02년도 고대 병원에서 단백뇨
소견으로 renal biopsy 시도하였으나 실패하였던 과거력 있음.
내원 3년 전부터 과로시마다 facial edema소견 보였으며 한달 전부터
상기 소견 악화되어 local clinic 방문하여 시행한 검사상 단백뇨, 혈뇨
보여 자세한 검사위해 본원 내원.

3. Past Medical history Personal History Family History
DM / HTN / Tb / Hepatitis ( - / -/ - / +)
Chronic hepatitis B (+) : 수직감염
Op Hx(+) : Lt . Shoulder dislocation op (2005년)
Medication : local clinic에서 이뇨제 처방받아 복용
Herbal medication : none
Personal History
Smoking (-)
Alcohol (+): 주1회, 소주 2병
Family History
어머니 : Chronic hepatitis B, HTN

4. Preclinical course 2002.9 2002. 12 2010.12.20 2011.1.4 CHB 고대병원
본원 IN OPD
본원 IN OPD
Adm
U/A
Protein (+~2+)
Occult blood (3+)
mRBC 30-60/HPF
24hr Urine
Protein 496mg/d
C mg/dL
C mg/dL
HBe Ag (+)
Chemistry
BUN/Cr 11/0.8 mg/dL
U/A
Protein (-)
Occult blood (3+)
mRBC 10-29/HPF
Chemistry
Pro/Alb 4.2/2.2 g/dL
AST/ALT 93/97 IU/L
BUN/Cr 10/1.0 mg/dL
U/A
Protein (3+)
Occult blood (2+)
mRBC 2-4/HPF
Microscopic hematuria
IG consult

5. Review of System General
generalized weakness (-) fatigue (-) facial edema (+)
febrile sense (-) chilling (-) weight change (-)
Skin
rash (-) itching (-) pigmentation (-)
Eye & ENT
visual disturbance (-) otalgia(-) rhinorrhea(-) sore throat(-)
Respiratory
cough (-) sputum (-) dyspnea (-) tachypnea (-)
Cardiac
chest pain (-) palpitation (-) orthopnea (-)

6. Review of System Gastrointestinal
A/N/V/D/C (-/-/-/-/-) dysphagia (-) abdominal pain (-)
hematemesis (-) hematochezia (-) melena (-)
Urinary
dysuria (-) frequency (-) urgency (-) gross hematuria (-)
residual urine sense (-) flank pain (-)
Musculoskeletal & Extremities
myalgia (-) LBP(-) both leg edema (+ / +)
Neurologic
syncope (-) seizure (-) numbness (-)

7. Physical Examination
Vital sign /80 mmHg – 84회/min – 20회/min – 36.6 °c
Ht: 171cm Wt: 57kg (BMI: 19.5 kg/m2)
General alert consciousness
not so ill - looking appearance
Skin rash(-) pigmentation(-) petechiae(-)
Head & Neck neck vein engorgement (-)
neck LN enlargement (-)
Eye & ENT isocoric pupil with PLR (++/++)
whitish sclera pinkish conjunctiva

8. Physical Examination
Thorax Clear breathing sound without rale, wheezing
Regular heart beat without murmur
Abdomen Soft and flat abdomen
Normoactive bowel sound
No tenderness / rebound tenderness
No palpable mass
No splenomegaly no hepatomegaly
Back & Extremities
CVA tenderness (-/-)
pretibial pitting edema (+/+)
motor: V V sensory:
V V

9. Initial lab finding CBC/DC Chemistry
6,730/mm² g/dl – 43.0% - 210K (seg 58.1%)
PT (INR) aPTT
Chemistry
TB mg/dL Prot/Alb /2.1g/dL( A/G ratio 1.1 )
AST/ALT /173 IU/L ALP/GGT 62/67 IU/L
BUN/Cr /0.9 mg/dL Na/K/Cl /4.0/104 mmol/L
CRP <0.3 mg/dl Uric acid mg/dL
Ca/P/Mg /5.0/2.1 mg/dL ( Corrected Ca : 9.1 mg/dL )
Cholesterol mg/dl Glucose mg/dl
LD/CK /2297 U/L
U/A
Occult blood (2+) Protein (3+) Glucose (-) Leukocytes (-) Nitrite (-)
RBC 5-9/HPF WBC 0-1/HPF

10. Chest X-ray ( )

11. EKG ( )
.Normal sinus rhythm
.Rightward axis

12. Initial problem lists
#1. facial edema, pretibial pitting edema #2. proteinuria #3. microscopic hematuria #4. hypoalbuminemia #5. hypercholesterolemia #6. elevated LFT #7. elevated CK, LDH #8. h/o chronic hepatitis B
Nephrotic syndrome
Acute exacerbations

13. Initial Assessment #1. Nephrotic syndrome #2. h/o chronic hepatitis B
r/o MCD
r/o MGN
r/o IgA nephropathy
r/o PSGN
r/o MPGN
#2. h/o chronic hepatitis B
r/o acute exacerbation
d/t drug
d/t alcohol
d/t other viral infection

14. Initial Diagnostic & Therapeutic Plan
#1. Nephrotic syndrome
D> Spot urine protein to creatinine ratio
24h urine collection
Abdomen US
Serologic marker
(complement level, ANCA, ANA, immunoglobulin, cryoglobulin, ASO titer)
viral marker
Dysmorphic RBC, urine MCV
if needed, Renal biopsy
T> If no renal a. , stenosis  ARB
Diuretics

15. Initial Diagnostic & Therapeutic Plan
#2. Chronic hepatitis B
D> Viral marker, tumor marker
( HBs Ag, Anti-HBs Ab, Anti-HBc Ab, Anti-HBe Ab, HBe Ag, HBV DNA Titer,
anti-HAV Ab, anti-HCV Ab )
Abdomen US
T> Antiviral agent

16. Clinical course

17. Abdomen & renal doppler (2011.1.5)
11.5cm
11.5cm
Rt kidney 11.5cm , Rt RI 0.5
Lt kidney 11.5cm

18. Viral markers
HBsAg
(+)
Anti-HBs Ab
(-)
Anti-HBc Ab
Anti-HCV Ab
Anti-HIV Ab
Anti-HAV IgG
VDRL
Serologic marker
IgG (mg/dL)
343
IgA (mg/dL)
119
IgM (mg/dL)
88.5
C3 (mg/dL) 91
C4 (mg/dL)
13.1
RA factor (IU/mL)
10.1
ASO titier
50.9
ANA -
P-ANCA
C-ANCA
Cryoglobulin
HBeAg
(+)
Anti HBe Ab
(-)
Real time PCR
>9.89 x 108 copies/mL
Tumor marker
AFP
2.57

19. Urine RBC morphology <5%
Urine MCV 88.2 fl
Urine MCV/serum MCV = 88.2/84.1 =1.04
Urine RBC morphology <5%
Spot urine
Protein/Cr ratio = 700/161 = 4.35 g/day
24hr urine collection
CrCl 75 ml/min
Total urine volume 3320 ml
24hr urine protein 5607 mg/d
24hr urine Cr 1195 mg/d

20. Renal biopsy

21. 200배 PAS

22. x400

24. C1q C3
Fibrinogen
IgA
IgG
IgM

25. U
END CL

26. LM Ⅰ. Glomerulus Ⅱ. Tubulointerstitium 1. Number of Glomerulus: 8
2. Glomerulosclerosis (GS): (Y) 3 / 8 (%)
Global glomerulusclerosis: 3 / 8 (%)
3. Capillary wall thickening: 3
4. Lumen of capillary: obliteration, focal
5. Capsular adhesion: (Y) 4 / 8 (%)
6. Duplication(Tram-track) of capillary wall: 2
7. Wire-loop formation of capillary wall: 0
8. Intraluminal hyalinosis: 0
9. Capillary necrosis: 0
10. Mesangial matrix expansion: 3
11. Mesagnial cell proliferation: 3
12. Mesangiolysis: 0
13. Inflammatory cell infiltration: 0
14. Crescent: (Y) 1 / 8 (%)
Cellular cresent: 1 / 8 (%)
15. Glomerulitis: 0
16. Periglomerular fibrosis: (Y) 3 / 8 (%)
Ⅱ. Tubulointerstitium
1. Mononuclear cell infiltration: 3
2. Neutrophilic infiltration: 0
3. Interstitial fibrosis: 3
4. Tubular atrophy: 3
5. Acute tubular necrosis: 0
6. Tubular cast: 1
7. Tubulitis (No/tubule): 1
Ⅲ. Vessels
1. Vasculitis, endotheliitis: 0
2. Necrosis: 0
3. Intraluminal thrombi: 0
4. Art. intimal hyalinosis: 0
5. Art. medial nodular hyalinosis: 0
6. Fibrous wall thickening: 0

27. IF C1q 12/12 - ++ C3 + IgA +/- IgG +++ IgM Antisera Number G.linear
G.granular
Mesangial
GCW
Tubules
Interstitium
Vessels
C1q
12/12 - ++ C3 +
Fibrinogen
IgA
+/-
IgG
+++
IgM

28. EM Diagnosis) Focal proliferative glomerulonephritis
Ⅰ. Glomerulus 1. Epithelium 1) Foot process effacement (Y, diffuse) 2) Deposits (N) 2. GBM 1) Thickness (nm) - thickening 2) Contour - no pathologic abnormality 3) Texture- no pathologic abnormality 4) Deposits (Y) - location: intramembranous, subendothelial - type: immune type 3. Mesangium: Deposits, increase of mesangial matrix 4. Endothelium: No pathologic abnormality
Diagnosis)
Focal proliferative glomerulonephritis

29. PCR Cr
Renal biopsy
2011.3
2011.6
2011.8
2012.3
exforge
Olmesartan 20mg qd
thiazide
Entecavir 0.5mg qd
DNA titer copies/ml
ALT
AST

30. Final diagnosis
#1. MPGN, type I a/w hepatitis B infection #2. Chronic hepatitis B