A 37-year-old man was transferred to Brigham and Women's Hospital for evaluation of progressive renal failure. His medical history was notable for intravenous drug use and heavy ethanol consumption but he denied their use for the last 7 years. He had had at least one bout of alcoholic hepatitis, which was diagnosed about 8 years previously. The patient originally presented to his physician 2 years ago with complaints of mild anorexia and fatigue. Workup at that time was remarkable for slightly elevated liver enzymes and a serum creatinine of 1.2 mg/dl. Six weeks later he noted the onset of periorbital edema followed by edema of the legs and a 20-pound weight gain. He consulted the emergency room of a local hospital for these symptoms one year ago, where he was noted to have elevated liver enzymes and a serum creatinine that had risen to 1.7 mg/dl. Urinalysis revealed 4+ protein and 2+ blood by dipstick; microscopic examination of the urinary sediment revealed red blood cells too numerous to count, 5 to 10 white blood cells/high-power field, and numerous hyaline and granular casts. He was referred to a nephrologist.

At physical examination performed by the nephrologist 2 days later, his pulse was 72 beats/mm; blood pressure, 160/110 mm Hg; and respirations were normal. No oral lesions were present, and funduscopic examination showed no abnormalities. The jugular venous pressure was estimated at 9 cm H20, and the thyroid gland was palpable without nodules. The chest was clear; cardiac examination revealed a normal rhythm with a soft S4. A grade II/IV systolic ejection murmur was audible. The abdomen was distended and soft but without tenderness, and no masses were palpable; bowel sounds were normal. The spleen was not detectable, but the liver edge was palpable 4 cm below the right costal margin. The extremities were remarkable for 3+ pitting edema up to the mid-portion of the calf. The skin revealed a discrete, papular, erythematous rash. Laboratory data included a white blood cell count of 30,200/mm3 with