by Cristiana Rollino Department of Nephrology, S.G. Bosco Hospital, Turin, Italy
The case AB, an 84 year-old woman, body mass index 22 kg/mq, was submitted in September 1999 to hemicholectomy because of carcinoma of sigma; at that period renal function was normal (serum Creatinine -SCr- 0.6 mg/dl, GFR according to the MDRD formula 82 ml/min). On the 13th of December 1999 she presented fever (38 °C) and right flank pain. On December 15th she was conducted to the Emergency Department: blood pressure was 130/80 mmHg, heart rate 95 beats/min, respiratory rate 18/min, Oxygen saturation 98%, temperature 39.5°C. Laboratory investigations disclosed renal failure (SCr 4.8 mg/dl), haemoglobin 8 g/dl, leukocytosis (24400/mm3), thrombocytopenia (73000/mm3), increased LDH (1935 U/l), AST (95U/l) and ALT (93 U/l). In the following days renal failure worsened (SCr 6.5 mg/dl) and the patient was admitted to our Department of Nephrology. Physical examination was regular, except for positive Giordano sign at the right flank. Blood pressure was 170/90 mmHg. Other examinations showed: SCr 7.4 mg/dl, K+ 6.2 mEq/l, Na+ 134 mEq/l, calcemia 7.5 mg/dl, haemoglobin 7.7 g/dl, platelets 40.000/mm3, leukocytes 24.000/mm3 (neutrophils 90%), INR 0.9, PTT 36”, D-Dimero 9.5 mcg/ml, ATIII 76%, total proteins 5 g/dl, albumin 1.9 g/dl, glucose 86 mg/dl, AST 132 U/l, ALT 52 U/l, alkaline phosphatase 186 U/l, gammaGT 38 U/l, LDH 900 U/l, CPK 43 U/l, bilirubin 0.9 mg/dl, C Reactive Protein -CRP- 36 mg/dl, haptoglobin 5 mg/dl (normal values 30-200 mg/dl). Schistocytes were absent. No monoclonal component was evident in serum or urine. In the urinary sediment 10-15 RBC/hmf, 8-10 WBC/hmf were found. Proteinuria was 1.2 g/24h, with an exclusive tubular pattern. Ultrasound examination of the abdomen showed normal sized kidneys, hyperechogenic cortex, and small parapyelic cysts. In the left kidney a cortical hyperechogenic area with a diameter of 4 cm was detected. Liver, gall bladder, biliary ways, spleen, pancreas, aorta and bladder were regular. Chest X-Ray did not reveal pathologic abnormalities.
Question 1) - Which diagnoses could be hypothesized? (Only ONE answer is correct)