A woman with type-1 DM who was 31 weeks pregnant presented for the second time in about a month with vomiting and a severe metabolic acidosis. The first time she had a pH of 7.3 with an HCO3 of 10 but an anion gap (AG) of only 12. Her blood glucose (BG) was 171, her betahydroxybutyrate (BHB) was 39 and she was assumed to have diabetic ketoacidosis (DKA), was treated as such and the acidosis resolved. Then 20 days later she developed a similar metabolic acidosis, HCO3 13, AG 16, BHB again elevated at 55, but her BG this time was only 114. She received 3 liters of normal saline (NS) and her acidosis worsened with her [HCO3] dropping to 8.
Introduction and Background A 46 y/o male with history antiphospholipid Abs on apixoban for DVT in 2012 was referred for renal failure and proteinuria. The patient was seen 9/17 with creatinine 1.6 mg/dl (1.1 in 1/16, 1.4 in 1/17), U/A 2+ protein, no blood, urine P/C ratio 146 mg/g. Serologic w/u normal including serum and urine immunofixation and serum free light chains (FLC): kappa FLC 45.6, lambda FLC 51.9 with a K/L FLC ratio of 0.9 (nl 0.37-3.1 in pts with renal insufficiency) https://tinyurl.com/yakoqt9d. A renal biopsy showed a mesangial proliferative GN with only IgG1 lambda by immunofluorescence consistent with “Proliferative Glomerulonephritis with Monoclonal Immunoglobulin Deposits” (PGNMID). The patient we seen by hematology and a bone marrow was nl including flow cytometry, fluorescence in situ hybridization (FISH), chromosomal studies and stains for amyloid.
Roger A Rodby MD FACP FASN and Susan Willner ASN Communities
Three years ago, the ASN developed and released ASN Communities with the objective of creating an international venue to network, collaborate and discuss important issues in a members-only environment. Since the launch:
Members have embraced the Communities for discussion and learning. Recently a conversation on “Lupus with New Proteinuria and Hematuria” provided such valuable real-life case information that it was used in a presentation on “When to do a Kidney Biopsy in Lupus Patients and Understanding Activity and Chronicity Scores” to the New York Academy of Medicine by Dr. Surya Seshan, MBBS, Weill Cornell Medical Center, who reported that attendees “loved the way I brought the ASN online exchange as an introduction to highlight the issue and my talk. I cannot thank you and all our experts enough for making this happen.”