Working Diagnosis:
Final working diagnosis was chronic kidney disease (CKD) secondary to IgA nephropathy (formally known as Henoch-Schonlein Purpura) secondary to a viral syndrome.

Treatment:
The patient required immunosuppression and a strict balance of electrolytes, protein intake, and hydration. Early diagnosis and intervention were vital to sustain kidney function until a transplant can be performed.

Outcome:
After extensive workup and modifications of the athlete's diet, electrolyte, and protein intake, the athlete maintained a GFR > 20. Electrolyte supplements and protein intake required constant revisions with evolving competition and climate changes. The athlete competed with close monitoring by primary care sports medicine (PCSM), nutrition, and nephrology. Hydration was crucial due to his Lisinopril and Jardiance, which increased dehydration risk. He followed a low-potassium diet with daily Lokelma. With a 21% risk of End Stage Renal Disease (ESRD) in 2 years, he was advised to join the renal transplant list to receive a donor kidney before needing hemodialysis (HD). Aware of the high HD risk, he explored preemptive transplant options and monitored for nausea, fatigue, bruising, or bleeding given his elevated BUN.

Author's Comments:
IgA nephropathy is the most common primary glomerulonephritis worldwide.1 The disease occurs when immune complexes are deposited into glomerular mesangium, triggering an inflammatory response, resulting in glomerular and tubulointerstitial inflammation and fibrosis.2-3 The gold standard for diagnosis is a kidney biopsy, which would show mesangial hypercellularity, endocapillary hypercellularity, segmental glomerulosclerosis, tubular atrophy/interstitial fibrosis, and crescents.2-3 Treatment involves strict blood pressure control, renin-angiotensin system blockade, sodium-glucose transporter 2 inhibitors, and glucocorticoids if high-risk.3-4
This case presented the challenge of helping an athlete maintain high level collegiate performance while preserving kidney function in the setting of significant CKD. It also demonstrates the importance of PCSM in coordinating the expertise of a multidisciplinary team of specialists to achieve an optimal outcome, both medically and on the court for this patient.

Editor's Comments:
As highlighted in this case, there are challenges in managing severe CKD and sports participation. Those challenges notwithstanding, regular exercise, individualized to each patient with CKD, can decrease blood pressure, increase cardiorespiratory fitness and help to improve kidney function.5
CKD can also present in pediatric patients, including due to renal manifestations of HSP. Thus, providers should recognize the clinical presentation of HSP and appropriately monitor and screen for renal involvement (with urinalysis and blood pressure checks) for up to 12 months, even after proper initial diagnosis and management.6

References:
Filippone EJ, et al. Contemporary review of IgA nephropathy. Front Immunol. 2024 Aug 12;15:1436923.
Stamellou E, et al. IgA nephropathy. Nat Rev Dis Primers. 2023 Nov 30;9(1):67.
Rauen T, et al. Intensive Supportive Care plus Immunosuppression in IgA Nephropathy. N Engl J Med. 2015 Dec 3;373(23):2225-36.
El Karoui K, et al. Treatment of IgA Nephropathy: A Rapidly Evolving Field. J Am Soc Nephrol. 2024 Jan 1;35(1):103-116.
Valenzuela PL, Castillo-Garcia A, Saco-Ledo G, Santos-Lozano A, Lucia A. Physical exercise: a polypill against chronic kidney disease. Nephrol Dial Transplant. 2024 Aug 30;39(9):1384-1391. doi: 10.1093/ndt/gfae062. PMID: 38460948.
Sestan M, Jelusic M. Diagnostic and Management Strategies of IgA Vasculitis Nephritis/Henoch-Schonlein Purpura Nephritis in Pediatric Patients: Current Perspectives. Pediatric Health Med Ther. 2023;14:89-98. Published 2023 Mar 7. doi:10.2147/PHMT.S379862

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