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Advanced Diabetic Nephropathy with Focal Proliferative Glomerulonephritis in a 44-Year-Old Female

A 44-year-old married female with a history of insulin-dependent diabetes mellitus (IDDM) presents with proteinuria (7 gm/24 hr) and microhematuria. Despite well-managed hypertension, her poorly controlled diabetes (HbA1c 9%) and renal impairment (GFR 31 ml/min) raise concerns. Previous screenings showed normal renal function. Investigation reveals chronic kidney disease (Stage 3) and nephrotic syndrome with glomerular changes suggesting superimposed IgA nephropathy. Renal biopsy confirms advanced diabetic nephropathy with focal proliferative glomerulonephritis.

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Advanced Diabetic Nephropathy with Focal Proliferative Glomerulonephritis in a 44-Year-Old Female

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  1. 204060810 U06-5523 DM with microhematuria

  2. 44 yr married female,mother of two children, • referred to the Renal clinic by family physician on january 27,2006 for investigation of protienuria with IDDM • H/O Diabetes- Dx 1990-Gestational Age 29 • Type 2- 7 years • IDDM—4 years • Having laser treatment for retinopathy-partial blindness Left eye—2 years • Patient has no urinary symptoms • Depressed-recent death of her mother • Presenting features: • Hypertension-143/83 on Rx with ARB/HCTZ • Poorly controlled diabetes- HbAIc 9% • Urine analysis-protein,blood and red cell cast • Nephrotic range proteinuria (7gm/24hr) • Serum creatinine-166umol/L • GFR-31ml/min/1.73m2(MDRD) • C3/C4-normal • Quantitive Ig-IgG,IgA and IgM-normal • ANA-negative • U/S abdomen-normal kidneys U06-5523

  3. U06-5523 Other medical conditions: 1.hyperlipidaemia 2.hypothyroidism 3.anemia-normochromic,normocytic 4.Migraine headache Past Health: Diabetes diagnosed with pregnancy age 29-1990:Scr 57umol/L 1997-Scr 70umol/L- no proteinuria 2002-Scr 70umol/L-no proteinuria Renal diagnosis: 1. Chronic Kidney disease-Stage3 2. Nephrotic range of proteinuria + Hematuria ? Diabetic nephropathy with other parenchymal renal disease Plan: Investigate- renal biopsy

  4. IF • IgG-moderate background • IgA- minimal but definite granular mesangial in several segments of the non-sclerotic glomerulus. • IgM- trace mesangial,close to negative • C3- moderate to strong vascular and Bowman’s capsule near the vascular pole,with a few tiny mesangial granules • C1q-negative • Kappa-moderate basement membrane background with a few mesangial granules of doubtful significance • Lambda-same as kappa • Fibrin- moderate interstitial staining • Albumin- moderate to strong basement membrane background

  5. IgA

  6. C3

  7. Kappa

  8. Lambda

  9. Fibrin

  10. Albumin

  11. Comment: As well as the obvious diabetic nephropathy, the IF supports the presence of a small amount of mesangial IgA deposition,and the EM although indeterminate is at least consistent. The picture indicates a component of IgA nephropathy, but the advanced diabetic changes are by far the predominant process here.

  12. Diagnosis:Renal Biopsy:Advanced Diabetic Nephropathy. Superimposed focal proliferative Glomerulonephritis on the basis of IgA Nephropathy.

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