U # ATN 1 year ago with recovery but now proteinuria with DM ?other diagnoses 49y Aboriginal male with DM dxd in 1989 and HT dxd in 2003 Several admissions to ER with high creatinines which then resolved, ? From volume depletion/ACE inhibition, elevated CKs Creatinine oscillating High grade proteinuria, 3+ since at least 2004, PCR of 707 on July HbA1c 10.1 in 2004, 7.2 in Nov 2006 UA tr- 1+ blood, 3+ protein, some dysmorphic rbc, no rbc casts, some granular casts C3, C4 normal, ANA, ANCA, anti GBM, SPEP, Hep B, Hep C negative Albumin 27, Cholesterol 7.14 CK of 900 on lipitor! Renal US normal kidneys BP shot up in October, requiring 4-6 meds for control, c/o puffy face and periodic pedal edema MRA no renal artery stenosis Creatinine Urine PCR ER, ? dehydration Renal clinic BP 121/72 BP 146/87 BP 194/107 BP 116/86 BP 117/80 IF IgG- Mild linear GBM staining, a common finding in diabetes. IgA- Mild to moderate mesangial staining. IgM- Mild mesangial staining. Mild vascular staining. C3- Mild to moderate mesangial staining. Moderate vascular staining. C1q- Moderate mesangial staining. Moderate vascular staining. Kappa and Lambda- Negative. Fibrinogen- Mild interstitial staining. Albumin- Mild to moderate linear GBM and TBM staining, a common finding in diabetes. Moderate hyaline droplet change in tubular cytoplasm. IgG IgA IgM C3 C1q fibrinogen albumin EM Will be ready in the coming weeks Diagnosis Renal Biopsy: Diffuse diabetic glomerulosclerosis with superimposed focal proliferative IgA nephropathy with occasional crescent formation.