1. U06-19912 #967529900 24 y.o. male ARF Creat 350 RBC casts + Active urine sediment

2. Renal Biopsy Rounds (November 3): 24 yo Asian male, previously well. ARF Cr max =355(spontaneously resolved) HPI Sept-Oct: Strenuous training for Edmonton Police Service Exam x several weeks (weight lifting, aerobic exercise) Unwell x 1 week prior to presentation: URTI and fatigue  rests Few days later: intermittent R sided abdominal pain (no flank pain, no radiation, no hematuria); no N/V/diarrhea October 18: performs EPS exam to point of exhaustion and syncope x 10 seconds (no preceding SOB/CP/palpitations, no seizure activity)  ER. Cr 291 ROS: No change in urine volume/color, no lower urinary sx. No constitutional/CTD sx. No SOB/orthopnea/edema. No cough/hemoptysis. No NSAIDS/tylenol/steroids/herbs (only whey protein supplements). No IVDU.

3. No Meds or Allergies. No family hx renal disease. Physical Exam (in ER after 5L NS) 150/90, P82 reg. 99% r/a. Afebrile. 82kg. U/O: 50cc/hr Euvolemic. Normal HS, no edema. Chest clear. Abdo: R mid-quadrant tenderness to moderate palpation; no rebound. No masses. ? Mild R CVA tenderness No rashes or synovitis

4. Labs [August 31, 2006: sCr=77, urine dip negative] sCr: 291 (Oct 18, 6am)  342 (4:30pm)  355 (Oct 19 6am) despite ++IVf Urine: 3+ Hb, 3+ protein (P/C=268), neg leuks/ketones. 25-50 RBC, 1-2 RBC casts. Una=42, Uosmol=204. FeNa=1.6%. Urine myoglobin cancelled by lab CK 362  265. Troponin -ve Serum lytes N, Ca=2.11, Po4=1.81, Albumin 36. CBC: Hb 149, Plt 255, WBC 12 LFTs, bili, TSH all N. Lipase 371. C3, C4 N. HepB,C,HIV –ve. ANA/dsDNA/ANCA/anti-GBM –ve. EKG: NSR, nil acute. AXR: ++stool; no obstruction/dilatation Renal Ultrasound: N size kidneys, no mass/hydro/stones. October 19: Renal Biopsy

5. IF IgG- Negative. IgA- Negative. IgM- Mild mesangial staining. C3- Moderate vascular staining. Mild mesangial staining. C1q- Negative. Kappa- Negative. Lambda- Negative. Fibrinogen- Moderate interstitial staining. Mild mesangial staining. Albumin- Negative.

6. IgM

7. C3

9. Fibrin

12. Diagnosis Renal Biopsy: Patchy severe congestion of glomeruli, arterioles and capillaries with foci of intense polymorph infiltrate. Rule out parasitic disease.

13. Comment Medullary foci of PMN inflammation and intense congestion are quite impressive and unusual It is likely that there has been considerable regional venous stasis brought about by the disease process (probable parasite forms in the cortex?) that has probably lead to the renal functional impairment

14. Comment Renal vein thrombosis seems ruled out by imaging studies. The congestion suggests that within the kidney there is quite profound venous obstruction or impairment of blood flow.

15. Schistosoma haematobium Causes inflammation + fibrosis leading to obstructive uropathy

16. Onchocerca volvulus

17. MRI/MRA renal vessels: normal October 20: sCr 281 October 23: sCr 127.. October 30: sCr=71