MAT# 18842113
Case synopsis:
46yo Romanian American woman has a history of frequent UTIs since she is a teenager. She is morbidly obese, has HTN, DBM II, and wounds on her legs that are diagnosed as vascular insufficiency. She treats with a PCP from 2023 through 2025 over which time, she has urinalysis and labs that are progressively concerning for kidney dysfunction. Eventually self-refers to nephrology 10/15/25, who does detailed workup for nephrotic syndrome. Eventually diagnosed with IgA nephropathy. Current kidney function is 20% and she is on the kidney transplant list waiting for a donor.
Outpatient Urinalysis shows:
8/4/20 – specific gravity 1.030, trace blood, ph5.0, negative protein.
9/8/20 – specific gravity 1.010, trace blood, ph 5.5, negative protein.
9/6/23 – specific gravity 1.025, 3+ blood, ph 5.5, protein 3+, Urine Creatinine 125; Urine Albumin 368.3, ratio: 2,946; culture: positive e.coli.
8/7/24 – specific gravity 1.016, ph 6.0, 2+ blood, protein 3+, few bacteria, Urine Creatinine 77, Urine Albumin 290, ratio 3,766
8/15/25 – specific gravity 1.013, ph 5.5, moderate blood, protein > 300, Urine Creatinine 66, Urine albumin “>200”
9/9/25 – trace blood, ph 6.0, negative protein
Outpatient Labs:
9/5/23 – BUN 19; Creatinine 0.80; EGFR 92;
8/7/24 – BUN 23, Creatinine 1.16, EGFR 59.
10/5/25 – BUN 36, Creatinine 2.46, EGFR 24
11/3/25 – BUN 50, Creatinine 3.31, EGFR 17
On 12/4/24, the PCP put her on Farxiga “due to presence of proteinuria, elevation in creatinine, decrease in EGFR and increase in blood sugars.” The PCP also charted that she would order a renal ultrasound, but a copy of the report isn’t in the chart. She continues to treat with the PCP over the next 10 months without a change in her management.
9/9/25, she self presents to a urologist she’d seen in the past. Urologist ordered a renal ultrasound that was performed 9/16/25, showing evidence of “chronic renal parenchymal disease”, 8mm right renal cyst, and small postvoid residual urine in the bladder.
She sees a nephrologist 10/15/25 who notes “unclear etiology of progressive proteinuria over the last 5 years.” He does an autoimmune workup, which is initially negative.
She has a hospital admission from 10/23-10/28/25 for fluid overload, where a kidney biopsy is performed and confirms IgA nephropathy with Oxford Classification Score M0, E0, S1, T2, C0.
The patient is currently under nephrology care and is awaiting kidney transplantation.
The issue for expert review is whether IgA nephropathy was diagnosable before October 2025 based on the available clinical presentation, laboratory data, pathology, etc.
If so, would earlier diagnosis likely have altered management or slowed progression of renal disease?
Also, opine on whether earlier diagnosis would have expected to preserve kidney function, to what extent, and whether it would likely have delayed progression to kidney failure or the need for transplant?
Thank you in advance and questions welcome.
Files:
Q: Is Obesity preventing treatment of IgA? The MEST scoring is ok , yet the patient is listed for kidney transplant.
A: —
Do you believe there might have been medical error?
The patient likely had IgA nephropathy for years, but many cases are stable and "smoldering" for many years. An indication she may have had IgA earlier was the trace blood on her urinalysis - but that is a nonspecific finding. Certainly by 2023, with the findings of a large amount of protein in the urine (when it was previously negative on UA values) the standard of care is referral to a nephrologist for evaluation. Diabetic nephropathy causes proteinuria, but this is a very rapid change for diabetic nephropathy in only a few years. She may have also noted increased leg swelling and/or very foamy urine in 2023 which would have been new.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Treatment of IgA nephropathy has undergone a revolution in the last several years. Previous to that there were no significant targeted therapies for IgA. In 2023, two medicines specifically FDA approved for IgA nephropathy were approved - Filispari (sparsentan) and Tarpeyo (budesonide). These two medicines began to be incorporated into clinical guidelines (in addition to standard prior therapies) by 2024. These medications provide a large benefit by decreasing proteinuria and preserving kidney function. Even in 2023, a nephrology consult would have been indicated and a biopsy considered at that time for the proteinuria.
What makes you a good expert for this case?
I treat many patients with IgA nephropathy and have for 15+ years.
How often do you encounter cases similar to this one in your practice?
I see 1-2 patients with IgA nephropathy per week.
Do you believe there might have been medical error?
The proteinuria was present before 2025 and an early nephrology referral may have lead to the diagnosis of IgA Nephropathy
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is likely that if the diagnosis of Ig A was made prior to 2025 when renal function was normal, the treatment options would have been more
What makes you a good expert for this case?
This is general bread and butter nephrology. Any good nephrologist would be a good expert. I consider myself to be a good nephrologist
How often do you encounter cases similar to this one in your practice?
Diabetes is well known cause of proteinuria and kidney disease. I see such cases atleast once a week
Do you believe there might have been medical error?
The case of this woman shows findings suggesting a downhill course of kidney function due to active, untreated glomerulonephritis. This was present in 2023, based on the presence of hematuria and proteinuria (near nephrotic range) at that time. The positive urine culture at that time could have led some to think the proteinuria was due to the urine infection. A repeat UA would have shown resolution of the infection but ongoing hematuria and proteinuria. A FU UA was completed in 2024 continued to show hematuria and proteinuria suggestive of active glomerular disease. The course was progressive as evidenced by the declining GFR noted in 2024 and then 2025 (eGFR 92 ml/min in 2023, 49 in 2024, and 24 in 2025). At the time of the biopsy there was substantial interstitial disease as evidenced by the T2 score in the biopsy. The likelihood she will recover significant kidney function in 2025 is low based on the T2 score. She would have been much more likely to have improvement in kidney inflammation (glomerulonephritis) and avoidance of a decline in kidney function if the diagnosis and appropriate treatment had been made earlier.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The time to intervene would have been between 2023 and 2024 before irreversible kidney damage had occurred as evidenced by the T2 score on the biopsy. Presuming the patient was adhering to recommendations, a fu UA would show ongoing signs of glomerular disease after the positive urine culture in 2023 and tx at that time, and possibly after the UA in 2024, would have led to treatment with potential stabilization of kidney function and less rapid progressions.
What makes you a good expert for this case?
I am familiar with IgA nephropathy and see cases where treatment leads to disease stabilization.
How often do you encounter cases similar to this one in your practice?
We see cases of untreated glomerular diseases 1-3 x year (including all types- ilncluding SLE). Many times, the lack of treatment is patient driven. Typically, in the setting of hematuria and proteinuria the course will be rapidly progressive if the inflammation cannot be suppressed.
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