MRCP2-4000

MRCP2-4000

A 38 year-old female patient presents with a four month history of abdominal distension, facial swelling and malaise. She has a past medical history of membranous glomerulonephritis. On examination, heart sounds 1 and 2 were present with no added sounds and the pulse was regular. Lung fields were clear, and abdominal exam reveals mild ascites. There was bilateral periorbital oedema with pitting oedema of the shins.

Blood tests reveal:

– Hb 8.8 g/dL
– Platelets 115 * 109/l
– WBC 4.2 * 109/l
– Mean corpuscular volume (MCV) 82 fl
– Na+ 148 mmol/l
– K+ 3.3 mmol/l
– Urea 9.2 mmol/l
– Creatinine 176 µmol/l
– Bilirubin 14 µmol/l
– ALP 91 u/l
– ALT 19 u/l
– γGT 68 u/l
– Albumin 32 g/l
– Cholesterol 7.9 mmol/l

Urinalysis reveals protein +++ and a 24-hour protein excretion is 5.2g.

The patient was started on high-dose diuretics and immunosuppression. Two weeks later, she presents with abdominal pain which is 6/10 on the pain scale and worse in her flanks. Her observations were normal apart from a temperature of 38.3ºC. Blood tests are performed and are similar to before except a raised creatinine to 314 µmol/l and a urea of 15.1 mmol/l.

What is the most likely reason for this patient’s deterioration in renal function?