The Case
42 year old doctor, body building fanatic, with history of mild hypertension, intermittent heavy NSAID use while playing college rugby, found to have elevated Cr to 1.4 to 1.7 since 2003. Nonproteinuric. Environmental exposures neg, denies drug or anabolic steroid use. Medications – lisinopril 5 mg/d. BP 134/84 mmHg, HR 66. Rest of the examination normal. Patient is very keen to know the cause of his renal insufficiency. Would you perform the biopsy? What would it likely show?
The Answer
I declined to perform a kidney biopsy on the patient, arguing that the biopsy would not reveal a lesion for which I would change my treatment. My clinical diagnosis was chronic interstitial scarring from chronic NSAID use in the past, coupled with high protein consumption as part of his body-building routine, and a high lean body mass from muscle. I was reluctant to recommend a biopsy because his history was suggestive of an etiology, renal function had been stable for many years, and his urinalysis and sediment examination was benign. The patient self-referred himself to another nephrologist and a biopsy was done. There were no complications from the biopsy.
There is no correct answer here.
The patient decided to see another nephrologist and persuaded him to perform a kidney biopsy. The result is below:
42 year old doctor, body building fanatic, with history of mild hypertension, intermittent heavy NSAID use while playing college rugby, found to have elevated Cr to 1.4 to 1.7 since 2003. Nonproteinuric. Environmental exposures neg, denies drug or anabolic steroid use. Medications – lisinopril 5 mg/d. BP 134/84 mmHg, HR 66. Rest of the examination normal. Patient is very keen to know the cause of his renal insufficiency. Would you perform the biopsy? What would it likely show?
The Answer
I declined to perform a kidney biopsy on the patient, arguing that the biopsy would not reveal a lesion for which I would change my treatment. My clinical diagnosis was chronic interstitial scarring from chronic NSAID use in the past, coupled with high protein consumption as part of his body-building routine, and a high lean body mass from muscle. I was reluctant to recommend a biopsy because his history was suggestive of an etiology, renal function had been stable for many years, and his urinalysis and sediment examination was benign. The patient self-referred himself to another nephrologist and a biopsy was done. There were no complications from the biopsy.
There is no correct answer here.
I think the correct decision was clearly not to biopsy as a biopsy was never going to change management. The only thing I might have done is formally measure GFR to reassure the patient as from what you say eGFR was under estimating his actual GFR
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