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Adrenal Incidentaloma Functional Workup — ESENeph MCQ

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HardHypertensionAdrenal Incidentaloma Functional WorkupESENeph

A patient has eGFR decline, proteinuria, microscopic haematuria and low C3. Serum testing shows a small IgG monoclonal protein that does not meet myeloma criteria. What is the decisive next diagnostic step?

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Correct answer: E — Bone-marrow biopsy defining the clone followed by empirical renal treatment

Explanation lettering: E = shown as A · A = shown as D · D = shown as E

D is correct. A small clone can produce nephrotoxic immunoglobulin despite failing criteria for overt malignancy, but monoclonal gammopathy is also common and may be incidental. Kidney biopsy with light microscopy, immunofluorescence and electron microscopy establishes whether the paraprotein is causing the lesion and guides subsequent clonal investigation and therapy. A permits progressive kidney injury while waiting for an irrelevant tumour threshold. B treats association as causation. C cannot identify the renal deposit or pattern. E delays tissue diagnosis. Biopsy risk is assessed, but the renal pathology is the defining link in suspected MGRS.

Reference: International Kidney and Monoclonal Gammopathy Research Group consensus on MGRS evaluation: https://pmc.ncbi.nlm.nih.gov/articles/PMC7136169/