In the clinic, you perform some additional diagnostic tests:
Urinalysis/microscopy, urine electrolytes
Choose the highest-yield tests below (many of these will be helpful)!
HIV viral load and CD4 count
It is important to assess this patient’s HIV viral load, which can increase his risk for certain types of kidney disease. His viral load is >1,000,000 copies/mL, and CD4 count is 120 cells/uL.
This would be a good choice for a patient with nephritic syndrome. Try again!
Hepatitis B and C serologies
Great choice! It is important to assess for HCV and/or HBV co-infection, as these viruses can lead to a variety of kidney pathology. This patient tests negative for HBV and HCV.
Rapid plasma reagin (RPR) test
Nice! This test can identify syphilis infection, which is an important cause of secondary membranous nephropathy and nephrotic syndrome.
Anti-PLA2R antibody titer
Absolutely! This is a useful test in a patient with nephrotic range proteinuria. An elevated antibody titer would be consistent with membranous nephropathy and, some would argue, could spare the patient a kidney biopsy. This will take approximately 1 week to result.
Urine eosinophils (Hansel’s stain)
Hm…this test has a low sensitivity, and its positive predictive value for acute interstitial nephritis (AIN) is only about 40%. Pick again!
Serum protein electrophoresis (SPEP) and free light chains
This is a reasonable test for a patient with nephrotic range proteinuria to assess for a monoclonal gammopathy, though his younger age makes this less likely. His SPEP shows hypergammaglobulinemia without an M-spike, and serum free light chains are within normal. Monoclonal gammopathies can lead to variety of glomerular diseases that cause nephrotic range proteinuria including amyloidosis and light chain deposition disease (LCDD).
Based on the information we have thus far, what are the top three diagnoses on your differential?
Systemic lupus erythematous (SLE) nephritis
HIV-associated nephropathy (HIVAN)
HIV-associated immune complex kidney Disease (HIVICK)
Hepatitis C- associated glomerular disease
Primary membranous nephropathy
Minimal change disease (MCD)
Acute interstitial nephritis (AIN)
Tubular dysfunction due to tenofovir
We need a kidney biopsy to make the diagnosis here! Click here to perform a percutaneous biopsy.