The case

A 74-year-od man presented at the clinic to evaluate his chronic kidney disease before a planned transcatheter aortic valve replacement.

History: He was diagnosed with pancreatitis 25 years earlier, and enlargement of the lacrimal and salivary glands had occurred.

Pathological examination of the kidney-biopsy specimen revealed glomeruli with thickened capillary walls and mild mesangial hypercellularity. A Jones silver stain showed "spikes" and "bubbles" in the glomerular basement membrane, features typical of membranous nephropathy. An infiltrate of mononuclear cells, plasma cells, and eosinophils, with tubulitis and without granulomas or neutrophils, was seen in the interstitium. Electron microscopy showed widespread amorphous subepithelial deposits along the glomerular basement membrane and in the mesangium, with surrounding spikes and podocyte foot-process effacement. Arteriosclerosis and glomerulosclerosis were also present.

Questions:

1. How would you interpret the findings?
2. What will be the management approach of the patient?

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Cortazar FB, Rhee EP, Gupta S, Sakhuja R, Stone JH, et al. A 74-year-old man with chronic kidney disease. N Engl J Med. 2020; 383:1768-1778. DOI: 10.1056/NEJMcpc2002415