case 4

During this admission she was also diagnosed with significant anaemia. However, she could not remember her haemoglobin level at the time of diagnosis. She denied any symptoms suggestive of anaemia prior to presentation. She was investigated thoroughly with multiple blood tests, upper and lower gastrointestinal endoscopy and a bone marrow biopsy. She was not aware of the outcomes of any of the above investigations. She was treated with the transfusion of two units of packed cells and discharged from hospital 10 days ago. She denies any known source of bleeding. She is currently stable but feels very lethargic.

LS was diagnosed with end-stage renal failure 5 years ago when she presented with frank haematuria, bipedal pitting oedema, dyspnoea at rest, persistent nausea and vomiting. She had multiple investigations including a renal biopsy. A diagnosis of end-stage renal failure secondary to IgA nephropathy was established. Almost immediately she was commenced on haemodialysis. She was dialysed for 2 years, initially at the hospital and then at home until 3 years ago, when she received a cadaveric renal allograft. Three months later she developed severe rejection non-responsive to pulse methylprednisolone therapy and she was recommenced on dialysis. Two years ago she received her second cadaveric allograft, which has been functioning well to date.

She has been treated with multiple immunosuppressant medications, including prednisone at various doses, azathioprine and cyclosporin, for 3 years.

She has received oral prednisolone as well as parenteral pulsed methylprednisolone at different times. The maximum dose has been 500 mg methylprednisolone intravenously for 3 days during the rejection episode of her first allograft. The minimum is 10 mg oral prednisolone, which is her current maintenance dose. She denies any adverse effects associated with her corticosteroid therapy, but she has never had her bone densitometry measured.

She also takes 150 mg cyclosporin twice daily. With her cyclosporin therapy she has experienced side effects of gum hypertrophy, hypertension and recurrent gouty arthritis. The first gout attack was 1 year ago. On controlling the acute gout attack with colchicine and local corticosteroid injection, she was commenced on allopurinol maintenance therapy, and the azathioprine she was on was replaced with mycophenolate mofetil. Since the commencement of maintenance therapy with allopurinol, she has not suffered from any acute exacerbations of gouty arthritis. Her cyclosporin level is monitored at the local hospital’s renal clinic at 2-weekly intervals and the most recent trough level has been 175 ng/L. Her cyclosporin-induced hypertension is managed with long-acting nifedipine 30 mg daily and she denies any side effects associated with this therapy. Her blood pressure is monitored at the local renal clinic every second week and has been well controlled at around 130/85 mmHg.

She is currently managed on 1 g mycophenolate mofetil twice a day. She denies any side effects associated with this therapy.

She has had multiple skin malignancies associated with her immunosuppression, excised over the past 3 years by her general practitioner and a plastic surgeon. The most recent was a squamous cell carcinoma removed from her forehead 2 months ago.

In summary, her medications are: cyclosporin-A, mycophenolate mofetil, prednisolone, nifedipine and allopurinol. She denies any allergy.

LS’s mother is 68 years old and suffers from emphysema and diabetes mellitus. Her father is 70 years old and has ischaemic heart disease. She is an only child.

She lives with her partner, aged 47, who is well and supportive. She has one daughter, aged 12, who is well. She lives in a farmhouse with only one step at the entrance. There are many animals living on the farm, including swine, cattle and various birds. She is independent with activities of daily living.

She gave up smoking 4 years ago, but prior to that she had a significant smoking history of 30 pack-years. She smokes marijuana once a month and consumes alcohol only very rarely.

She works as a gardener at a local nursery and has prolonged periods of sun exposure.

My dietary history of LS suggests satisfactory nutrition. She denies any significant weight loss in the recent past. She has no problems with sleep.

She had an episode of depression about 4 months ago, due to a dispute with her partner. She believes that he is getting tired of all her medical problems. She is also anxious about the current developments with her medical condition. She denies any vegetative symptoms of depression or anxiety.

Her pulse rate was 50 beats per minute, regular in rhythm and normal in character. Her blood pressure was 140/95 mmHg and there was no postural drop. Her respiratory rate was 10 per minute. The estimated body mass index was 20. She was afebrile and her cognition was preserved.

Respiratory tract examination showed normal chest expansion, in both the apical and basal regions. There was no area of dullness to percussion, and breath sounds were vesicular throughout. There were fine crepitations in the right lung base. There was no sputum mug available for inspection.

Cardiovascular system examination showed no palmar crease or conjunctival pallor. Her heart sounds were dual and normal in character and there was no murmur. There was no peripheral oedema.

In the gastrointestinal system examination, her abdomen was not distended or tender. There was a longitudinal scar of 4 cm in the left lower quadrant, underneath which a non-tender, firm mass suggestive of the renal transplant was palpable. There was no organomegaly and the rest of the abdominal examination was unremarkable.

Neurological examination showed an unremarkable cranial nerve examination. Her visual acuity was preserved at 6/6 without correction. Fundoscopy showed silver wiring of the arteries and arteriovenous nipping with no haemorrhage or exudates. Fundoscopic findings suggest grade 2 hypertensive changes according to the Keith-Wagener-Barker classification.

Upper and lower limb examinations showed normal tone, power, reflexes and coordination with an unremarkable sensory examination. Importantly, there was no proximal muscle wasting or weakness noticed.

Her rheumatological examination was unremarkable and there was no lymphadenopathy.

In summary, LS is a 45-year-old renal transplant patient with a recent diagnosis of anaemia. She is on multiple immunosuppressive medications with associated complications of hypertension, gout, recurrent infections and cutaneous malignancy. She suffers from occasional depression and anxiety. She also has the important problem of hazardous occupational sun exposure.

The main problem with this woman is the management of immunosuppression appropriately so as to minimise complications and maximise graft survival and function.

In approaching the management of this patient, I have identified the following five problems:

First I would address the problem of anaemia. The first differential diagnosis I would consider is bone marrow suppression associated with immunosuppressive therapy. Other differential diagnoses that I would consider in this situation are:

To ascertain the severity of the anaemia and to exclude the above differential diagnoses, I would like to see the results of the following investigations: