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Renal biopsy: still a game changer

We report the case of a melanodermic 55-year-old male patient admitted to the emergency department with headache and vomiting for less than 24 hours. He had no known kidney disfunction or other medical history. On admission he was hypertensive (215/116mmHg), with no other relevant findings on physical examination. Bloodwork showed anemia (hemoglobin 9.8g/dL), kidney injury (creatinine 7.53mg/dL, urea 170mg/dL), metabolic acidosis and hyperkalemia. Urinalysis revealed occasional proteinuria 70mg/dL (urine protein to creatinine ratio 0.7g/g) and erythrocyturia of 154u/L. Renal ultrasound revealed symmetrical normal-sized kidneys with normal corticomedullary differentiation. Further laboratory tests revealed: 175.000/uL platelets, albumin 3g/L, LDH 284U/L (without haptoglobin reduction or schistocytes on smear blood test), fasting blood glucose 98mg/dL, hemoglobin A1c 5.3%, negative serologic tests for B and C hepatitis and HIV infection, normal serum protein electrophoresis, normal serum free kappa and lambda chains without abnormal ratio, normal C3 and C4 levels and negative immunological panel including ANA, ANCA and anti-GBM. He also underwent transthoracic echocardiography and fundoscopy examination, which documented concentric hypertrophy and grade 2 hypertensive retinopathy, respectively.