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A renal biopsy revealed uniform thickening or the glomerular basement membrane on H and E stain without any cellular proliferation. A spike and dome pattern was observed on silver staining of the same biopsy. The most likely presentation of this patient would have been
A 35 year old normotensive male with pedal edema and hyperlipedma
39 year old male with hematuria, hemoptysis, hypertension and proteinuria
5 year old female with anasarca, massive proteinuria and oval fat bodies in the urine
60 year old cachetic male with a mass in the left flank and urinalysis showing RBC casts
22 year old male with recurrent episodes of microscopic hematuria

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GBM thickening on HE without proliferation raises the suspicion of membranous nephritis. On silver staining the GBM appears to have spikes and domes and this can be further confirmed on EM. The uniform spikes are characteristic for membranous nephritis.

From all the clinical scenarios the 60 yo man with renal mass has RBC casts and hence glomerular lesion is most likely to have membranous nephritis secondary from cancer. The age appropriate cancer screening is paramount in patients with membranous because sometimes the cancer becomes clinically apparent few months after the initial diagnosis of membranous nephritis. Another common cause of secondary membranous nephritis is lupus in which case the immunofixation will show full house. We can now use PLA2R to distinguish between primary vs secondary membranous nephritis - see

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