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Endgames Case Review

A 65 year old man with macroscopic haematuria and acute kidney injury

BMJ 2016; 353 doi: (Published 10 May 2016) Cite this as: BMJ 2016;353:i2180
  1. Richard Germann, advanced trainee in nephrology1,
  2. Kannaiyan Rabindranath, consultant nephrologist1,
  3. Daniel Ninin, consultant pathologist2,
  4. Peter Sizeland, consultant nephrologist1
  1. 1Regional Renal Unit, Waikato Hospital, Hamilton 3240, New Zealand
  2. 2Department of Pathology, Waikato Hospital
  1. Correspondence to: R Germann richardgermann{at}

A 65 year old man who presented to his general practitioner with a three day history of bright red, painless, macroscopic haematuria was found to have a raised serum creatinine of 461 μmol/L (reference range 60-105) (estimated glomerular filtration rate 11 mL/min/1.73 m2). His baseline serum creatinine had been stable (~120 μmol/L) for five years until one month earlier, when he had an episode of acute kidney injury while in hospital for cellulitis of the right leg. After discharge the cellulitis had resolved but his serum creatinine had remained raised at 252 μmol/L. He denied any recent respiratory infections, weight loss, night sweats, lethargy, or haematuria.

His medical history included hypertension, type 2 diabetes, chronic kidney disease stage 3, coronary artery bypass grafting, atrial fibrillation, an ischaemic stroke, benign prostatic hypertrophy, and tobacco use. His regular drugs (all once daily) were digoxin 125 μg, atorvastatin 80 mg, tamsulosin 400 μg, metoprolol 95 mg, aspirin 100 mg, and warfarin.

On physical examination his blood pressure was 116/70 mm Hg and he had mild pedal oedema. Urine analysis showed gross haematuria and proteinuria (protein:creatinine ratio 51.2 mg/mmol; reference <23).

His international normalised ratio (INR) was raised, at 5.7.

He was referred urgently to hospital, where a renal ultrasound showed normal sized kidneys with no hydronephrosis. Antinuclear antibodies and antibodies to hepatitis B, hepatitis C, and HIV were all negative. Complement factors C3 and C4, serum electrophoresis, and serum free light chains levels were all unremarkable.

In the absence of an anti-neutrophil cytoplasmic antibody result, which was subsequently reported as negative, he was given 1 g of intravenous methylprednisolone as empirical treatment for a possible vasculitis. Prothrombin X and 10 mg of intravenous vitamin K were also given to correct the clotting defect and facilitate kidney biopsy (fig 1).

Fig …

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