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History

History. A 50 y/o was referred for evaluation of azotemia .

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History

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  1. History • A 50 y/o was referred for evaluation of azotemia. • 10 yrs ago, he experienced sudden onset of pain on his right big toe. His serum uric acid was elevated. He was diagnosed to have gout and was prescribed medication but he was poorly compliant. The gouty attacks recurred lately hence, he decided to undergo thorough check-up. He denies dysuria, flank pain or hesitancy. He has nocturia.

  2. Physical Exam • BP is 120/70 • Obese • numerous tophi in his metacarpo-phalangeal elbow joint • no edema

  3. Salient Features • A 50 y/o obese male diagnosed 10 years ago to have gout with gouty attacks recurring lately and was referred for evaluation of azotemia • Patient experiences nocturia but there is no dysuria, flank pain or hesitancy, and edema • BP is 120/70 • Numerous tophi in his metacarpo-phalangealelbow joint

  4. Clinical Impression • Gouty nephropathy • Patients with prolonged forms of hyperuricemia are predisposed to a more chronic tubulointerstitial disorder, often referred to as gouty nephropathy • Distinctive feature: presence of crystalline deposits of uric acid and monosodium urate salts in kidney parenchyma • These deposits not only causes intrarenal obstruction but also incite an inflammatory response leading to lymphocytic infiltration, foreign-body giant cell reaction and eventual fibrosis

  5. Gouty nephropathy • Clinically, gouty nephropathy is an insidious cause of renal insufficiency. • Early in its course GFR may be near normal despite focal morphologic changes in medullary and cortical interstitium, proteinuria and diminished urinary concentrating ability

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