56 year old - sof

[ArchivalUser]

A 56-year-old man presents to your office complaining of fatigue and persistent joint pain for three months. His past medical history is significant for hypercholesterolemia, hypertension, and hepatitis C from injection drug use in the distant past. He has not been treated for hepatitis. He has no drug allergies.

His physical examination is remarkable for a right ventricular heave and a soft holosystolic murmur at the right sternal border. His abdomen is soft, with a liver edge palpable three centimeters below the costal margin and splenomegaly. There are purpuric lesions on his skin. There is no joint deformity or muscle atrophy. Laboratory studies reveal the following:

Hemoglobin 12 g/dL; platelets 410,000/mm3; BUN 47 mg/dL; creatinine 3.2 mg/dL; glucose 130 mg/dL, serum bicarbonate 20 mEq/L; total bilirubin 1.2 mg/dL; AST 88 U/L; ALT 110 U/L.

C3 and C4 levels are low. Rheumatoid factor is positive at a high titer.

Urinalysis -- protein 3+, hemoglobin 1+, with 50 red cells and no white cells or casts.

Immunofluorescence of the renal biopsy shows large glomerular intracapillary deposits, with granular subendothelial deposits outlining the glomerular capillary walls.

What would be the next appropriate step in the management of this patient?

(A) Kidney transplant
(B) Hemodialysis
© Prednisone
(D) Interferon and ribavirin
(E) Cyclophosphamide

[ArchivalUser]

cryoglobulinemia associated with HCV . DDD

[ArchivalUser]

yes d.

[ArchivalUser]

D..........

[ArchivalUser]

Yes D causing membranoprolifertal glomerulonephritis

but my question is do we treat the kindey problem 1st or will rx the Hep C resolve kidney problems?

[ArchivalUser]

This patient seems to have glomerulonephritis from cryoglobulinemia secondary to the chronic hepatitis C virus (HCV). Systemic manifestations of cryoglobulinemia include fatigue, arthralgias, hepatomegaly, Raynaud's phenomenon, mononeuritis, and purpuric skin lesions. Most patients with HCV-associated cryoglobulinemia are treated with antiviral agents, such as interferon and ribavirin to control the infection. Cryoglobulinemia from other causes ("essential cryoglobulinemia") is treated with high-dose steroids, cytotoxic medications, and plasmapheresis when it is acute and severe. Dialysis and transplantation can be used when the disease is extremely severe, but recurrences in the allograft can occur in 50 to 70% of cases. Cryoglobulinemia is a pathologic condition caused by the production of circulating immunoglobulins that precipitate upon cooling. It is associated with a variety of infections, collagen vascular diseases (such as lupus), and lymphoproliferative diseases (such as myeloma and Waldenström's macroglobulinemia). The diagnosis is made by demonstrating circulating cryoglobulins in patients with palpable purpura, renal insufficiency, and hypocomplementemia. Hypocomplementemia, especially of C4, is a helpful finding. The rheumatoid factor can function as a "surrogate marker" for cryoglobulins. The actual test for cryoglobulins can be difficult because of technical reasons. A positive result is only manifest when the serum is cold. If the serum is warm when the test is run, it will be falsely negative. Therefore, a positive rheumatoid factor can be found more easily as a marker of the presence of cryoglobulins. Recent studies have documented the hepatitis C virus as a major cause of cryoglobulin production in most patients previously believed to have essential mixed cryoglobulinemia.

[ArchivalUser]

so whats the answer...steroids or transplant??

[ArchivalUser]

Most patients with HCV-associated cryoglobulinemia are treated with antiviral agents, such as interferon and ribavirin to control the infection. Cryoglobulinemia from other causes ("essential cryoglobulinemia") is treated with high-dose steroids, cytotoxic medications, and plasmapheresis when it is acute and severe. Dialysis and transplantation can be used when the disease is extremely severe, but recurrences in the allograft can occur in 50 to 70% of cases

[ArchivalUser]

tx ben!!