A middle aged man w/ IVDU, HCV presented with worsening recurrent edema, found to have nephrotic syndrome.
Mnemonic for remembering low-complement glomerular disease: “C-LESS”
Cryoglobulins (+other types of MPGN which is the histologic dx for cryo)
Staph and Strep infections
Treatment of HCV-mediated cryoglobulinemia:
-All patients should be treated with antivirals for HCV
-There are specific indications for the addition of immunosuppression, including rapidly rising creatinine AND nephrotic range proteinuria (rituximab is usually first line though prednisone can also be used)
An older female w/ HCV p/w shortness of breath and volume overload, found to have proteinuria, hyertension, and hypoalbuminemia. Urine sediment showed dysmorphic reds, and complement levels were low. The diagnosis of GN with nephrotic features was made, thought likely 2/2 MPGN given her history of untreated HCV and complement levels; final results of a renal biopsy are pending.
Main Teaching Point:
Nephritic/Nephrotic syndromes represent a spectrum of disease. The syndromes that most often present with both nephrotic and nephritic features include MPGN, membranoproliferative glomerulonephropathy, and lupus nephritis. Generally, the mixed syndromes are the most severe – exceptions include RPGN (mostly nephritic) and HIV nephropathy, which both can quickly progress to ESRD.
*When you want to estimate CVP and can’t see the IJ:
-The EJ has been validated as a reliable surrogate (Vanayak AG et al. “Usefulness of the external jugular vein examination in detecting abnormal central venous pressure in critically ill patients”. Arch Intern Med 2006.)
– Hand raise (watch for hand veins to flatten as you lift arm towards heart level)
– Ultrasound to look at IJ or IVC