I have a case for which I would appreciate other’s thoughts.
A 19 year old male with biopsy proven FSGS treated with n prednisone, tacro, cellcept for many years, but unfortunately progressed to needing dialysis several months ago.He still has a good urine output (~ 2L/day) but has heavy proteinuria spilling 35 g of protein per day. His albumin values on last two monthly blood tests were 0.7 g/dl. Obviously he is at risk for hypoalbuminemic related complication. how can i shut down his kidneys to halt the protein loss? It seems to me that radiographic embolization would be preferable to either nephrectomy or medical nephrectomy with high dose NSAIDs.
Does anyone have experience with this situation?
I treated a dialysis patient with membranous glomerulopathy not responding to immunosuppression – hence dialysis – with 32 grams proteïnuria, albumin 1.5 G/dl, a lot of edema and low blood pressure with NSAID maximum dose and ACE inhibitor. Diuresis was 0.7 L/day. Very effective! . Don’t forget ppi. Patient is doing very well now. NSAID was discontinued after a few months.Albumin increased rapidly. Edema resolved. Course was actually complicated by rapidly increasing blood pressure and pulmonary edema due to rapid shift of fluid from interstitium to vessels.
Embolization is a very painful procedure. There is a lot of pain and the dead kidney has to heal up, with his low albumin I see increased risks, slow healing, increased risk of infection. Im not in favor of surgical removal or embolization. I would for sure try ARB, NSAIDs and Conservative management before deciding embolization.. An alternative option would be ureteric ligation done by laparoscopy. Renal artery embolization should be your last resort in this case.
This case and its references maybe helpful.
https://www.jstage.jst.go.jp/article/internalmedicine/50/23/50_23_2899/_pdf