77-year-old man with a type 2 DM presents with worsening renal function and proteinuria

freecme000
Published on Feb 10, 2022
77-year-old man with a history of uncontrolled type 2 DM for 9 years, , DM retinopathy and hemoglobin A1c (10.1%) , well controlled HTN presents to clinic for evaluation of worsening renal function and proteinuria, worsening fatigue, dyspnea on exertion. Over the Past 12 months creat increased from 1.4 to 2.5 mg/dL and 24 hr urine protein increased from 750 mg/day to 5 g/24 h .

Home Meds - Losartan ,Insulin, Invokona. Recent medication changes over the past 1 year include addition of SGLT-2 inhibitor Invokona for DM management and also was started intravitreal injections of bevacizumab (Avastin) (1.25 mg) in both eyes every 8 weeks for ARMD ( Age related macular degeneration) .Blood pressure was 119/70 mmHg. Per 3 plus pitting edema -necrotic skin ulcer in feet.

LABS - SPEP/IFE showed M spike at 2 gm/dL - LDL 170 mg/dl, TG - 450 mg/dl range ,albumin 2.3 g/dL. UA show some red blood cell casts. CBC showed thrombocytopenia (76) and mechanical hemolytic anemia: hemoglobin =6.5 g/dL, high reticulocyte count of 5 %, presence of schistocytes, Lactate Dehydrogenase (LDH) = 3258 UI/L and low haptoglobin. Renal Biopsy was formed and image as above. IF shows no evidence of Immune complex deposits or c3. Antinuclear factors were negative, as were antibodies for antiphospholipid syndrome and scleroderma. ADAMTS 13 activity was 120% of reference range activity, complement investigations were normal (C4, C4, CH50, Factor I and H, anti-Factor H antibody). cyroglobins lab test normal.

Most Likely cause for worsening renal failure is -

A. Progression of Diabetic Nephropathy
B. Avastin ( Bevacizumab ) use in last 1 year
D. RVT due to nephrotic syndrome
E. Type1 Cryoglobulinemia from monoclonal gammopathy

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https://renal.medcase.com/free_cme/238850/