부산대학교 도서관

A 73-year-old female patient with a history of systemic lupus erythematosus for 10 years presented with acute renal failure and a creatinine of 2.9 mg/dl (256 μmol/l). The patient had a baseline creatinine of 1.0 mg/dl (88 μmol/l) 3 months prior. Past medical history included sicca syndrome, Raynaud's phenomenon, longstanding low-grade proteinuria (<1 g/day) with minimal microhematuria, and persistently positive anti-nuclear and anti-double-stranded DNA antibodies. There was no history of diabetes or hypertension and the patient had not previously undergone renal biopsy. Physical examination revealed a blood pressure of 139/72 mm Hg and no edema or cutaneous manifestations. Her medications included methotrexate (MTX) 7.5 mg once per week (for 3 years) and plaquenil 200 mg twice per day. Urinalysis revealed 2+ protein and 1+ blood. Urine microscopic examination showed 6-10 red blood cells/high power field but no red blood cell casts. Laboratory evaluation revealed normal C3 and C4 complement levels, negative anti-nuclear cytoplasmic antibody, negative anti-cardiolipin antibody, normal erythrocyte sedimentation rate, serum albumin 3.4 g/dl (34 g/l) (normal range 3.5-5 g/dl (35-50 g/l)), and no evidence of a monoclonal serum spike. The kidneys measured 13.9 and 14.8 cm in length by ultrasound, without evidence of obstruction. This contrasted with a renal ultrasound from 7 years prior in which the kidneys measured 10.2 and 11.3 cm in length. Computed tomography (CT) scan revealed bilateral diffuse enlargement and hyperdensity of the kidneys (without mass lesions), a 1.5 cm mass in the left lower lobe of the lung, and multiple hypodense areas within the liver. Liver biopsy showed fibrosis, without evidence of neoplasia. The patient's creatinine rose further over 1 week to 3.9 mg/dl (345 μmol/l). Renal biopsy was performed.