Renal impairment resulting from hypothyroidism

A 37-year-old woman presented with recent constitutional upset and a year-long history of swelling of her face and hands. Her past medical history included pre-eclampsia. Her father had suffered from focal segmental glomerulosclerosis and her brother underwent renal transplantation for reflux nephropathy. Examination revealed peri-orbital oedema and hypertension (140/100 mmHg). Her pulse rate was 58 beats/min. Investigations included haemoglobin 11.6 g/l, white cell count 6.2 × 109/l, sodium 137 mmol/l, potassium 3.6 mmol/l, creatinine 148 μmol/l, estimated glomerular filtration rate (GFR) 37 ml/min/1.73 m2, urea 7.6 mmol/l, cholesterol 9.8 mmol/l, alkaline transferase 97 IU/l, alanine transaminase 45 IU/l, alkaline phosphatase 89 IU/l, albumin 45 g/l, calcium 2.37 mmol/l and glucose 4.9 mmol/l. Hepatitis, Epstein-Barr and cytomegalovirus serologies were negative. Urinalysis was normal. A 24-h urine collection identified 0.30 g of protein and a creatinine clearance of 58 ml/min. Ultrasonography revealed her kidneys to measure 11 cm on the left and 10 cm on the right. A small pericardial effusion was evident on echocardiography, with no left ventricular hypertrophy. Magnetic resonance angiography revealed patent renal arteries. A renal biopsy was undertaken. Twenty-two glomeruli were available for analysis, with no evidence of focal