Do we have to perform a renal biopsy? Clinical dilemmas in a case with nephrotic syndrome

Abstract

Renal biopsy is one of the pivotal diagnostic tools used in the field of nephrology. A morphological analysis of the kidney may also be of value for the overall management of patients with diabetic nephropathy. However, the indications for renal biopsy differ considerably among nephrologists, and no global consensus regarding performing this procedure among diabetic patients with various renal manifestations has yet been achieved. In this report, we would like to describe our serendipitous experience with a male type 2 diabetic patient presenting with nephrotic syndrome complicated by concurrent gastric carcinoma. We also discuss several conundrums that arose in the current case, which had an impact on our diagnostic and therapeutic decisions.

Keywords: diabetic nephropathy; membranous nephropathy; nephrotic syndrome; paraneoplastic glomerular injury; renal biopsy.

Figure 1

A photomicrograph of the EMR specimen. A type 0–IIc lesion with a well-differentiated adenocarcinoma with negative lymphovascular involvement was found (hematoxylin and eosin stain). The scale bar is indicated.

Figure 2

The renal biopsy findings. (A) A low power view showing the diffuse distribution of glomeruli with various stages of diabetic glomerular injuries, including glomeruli with hyalinotic lesions (narrow arrow), a moderate increase in mesangial matrix and thickening of the capillary wall (medium arrow), as well as nodule formation (wide arrows) (periodic acid-Schiff stain). Two sections of the same glomerulus with nodular lesions (B) and enormous exudative lesions with some bubbles, probably representing plasma proteins/lipids (C) (upper panel, periodic acid-Schiff stain; lower panel, periodic acid methenamine silver-Masson trichrome stain). The scale bar is indicated in each panel.