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 A patient with Renal Failure  

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A 67 year old male patient is sent to you for evaluation of his renal failure....
His Lab findings are as following:
Na+: 135 mEq/l
K+: 4.3 mEq/l
Cl-: 110 mEq/l
HCO3-: 24 mEq/l
Glucose: 100 mg/dl
Ca+: 11.9 mg/dl
PO4: 4.3 mg/dl
Albumin: 4.0g/dl

Creatinine clearance: 55 ml/min
Protein: 6.0 g/day
Hematcorit: 29%

1...Based on the findings above what 3 investigations are important to diagnose the case.

2...And calculate the anion gap and explain why it is in that range in this patient.
3...Name the various ways by which this condition can cause Renal failure



I guess I had to make you re-notice the existence of this post...

Just look at these
Creatinine clearance: 55 ml/min
Protein: 6.0 g/day
Hematcorit: 29%

so what do we have......A patient with renal failure...(it says that in the title) and anemia and sever proteniuria........

what do u do when u see massive proteinuria like this....u go check the other parameters of Nephrotic syndrome...... doesn't say and since it doesn't say then the patietn deosn't have any edema
2..Hypoprotenimia.....uh huh..... his serum albumin is normal...therefore this is not Nephrotic syndrome....

SO have a pateint with anemia, renal failure and non-nephrotic massive proteinuria...

It is simple

answer the questions??


I'll give a try and open the discussion.

An old man + renal problems + proteinuria + normal albuminemia + anemia = possibly multiple myeloma.
If it's not the albumin that is lost in urine than it has to be the globulines and the first one in my mind is Ig.
The anion gap 135 - (110 + 24) = 1 is like nonexistent (n=12) and paraproteinemia (multiple myeloma) is a common thing on the list for low anion gap.

I would ask bone x-rays, electrophoresis, bone morow exam (maybe plasma cells)


grin grin grin grin Thank you ....Thank you
Thank you

grin grin grin grin

Totally correct.......
This is most likely a case of multiple myeloma or at least one of the paraprotenemias....

and ur explanation is more than enough....nothing else is needed..... grin

Another thing the patient also has hypercalcemia....well there isn't anything more typical than this......

the last question....what is the usual causes of Renal failure in these patients.....
1....Ig Tubular casts....
2....Amyloidosis, type AL...
these are the most common causes
others can be ATN

Thank you once again

I guess people will look at it now and say uh huh..hehe


Well this still stands to Multiple Myeloma.....

You can see the Lab findings of this case....typical

An old man + renal problems + proteinuria + normal albuminemia + anemia+ hypercalcemia = possibly multiple myeloma.

Now ...Questions about this case....and any ideas about presentation of the paraprotenemias are welcome....and as Prep4usmle said.....

open the discussion.... grin


This pt has evidence of Multiple Myeloma as he is losing massive amounts of albumin in the urine.
The total protein loks normal due to the M component and you do a serum protein electrophoresis to demonstrate that.
His Ca++ will go up. DO a bone marrow asp/biopsy and refer him for total bone scan ( to exclude possibility of pathol.fractures) and send him to chemo


Correct again.......

But now tell me...
What other typical findings on Lab results other than the ones depicted in the case would you expect to see and that includes Bone marrow result? 8)


Yeah that was me forgetting to log in again...but it is okay...hehehe


Serum Protein electrophoresis will show a elevation in the Gamma region indication the M-component
- ESR will be markedly raised ( > 120)
-Urine proteinuria 3+ or more
-Bone marrow - infiltration by PLASMA cells

These are enough to make a defnitive diagnosis of Multiple Myeloma


Yes i know......

ESR is markedly raised...... Why? smiling face

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