Alexandra Garcia was just 20 years old when came to me from the pediatrics nephrology clinic with urine that contained blood I could see only with the help of a microscope and nearly a gram of protein when normal is less than 150 milligrams. The reason why was presumed to be the same as the reason that caused her mother and brother to also have microscopic hematuria and proteinuria—thin basement membrane disease.
Thin basement membrane disease is caused by a defect in a type of collagen passed on in families that, as the name implies, makes the membrane covering of the kidneys’ filtering units—the glomeruli—too thin to keep all the blood and almost all the protein in the body that a normal thickness membrane can. If I had to have a kidney disease, this is one I would choose because people with it do really well.
Alexandra’s mother had a kidney biopsy to prove she had thin basement membrane disease, but I would continue to “presume” with Alexandra because our biopsy needle wouldn’t be able to reach her kidney—she was nearly 300 pounds and built like a Fuji apple with limbs. Her weight alone could explain the protein in her urine, causing parts of her glomeruli to scar down to non-functional nubbins, so her prognosis probably would not be as great as if she had thin basement membrane disease alone.
No matter, because the treatment was the same: an ACE inhibitor. Angiotensin Converting Enzyme inhibitors are a class of blood pressure medications that are especially good at lowering the blood pressure within the kidneys so the filters’ holes have a chance to heal and allow less protein to pass through. She was already taking a small dose of an ACE inhibitor prescribed by her pediatric nephrologist. My job was to advise her to lose weight and increase the ACE inhibitor dose until the protein in her urine was less than 300mg unless she became dizzy from low blood pressure first.
Nearly a year later, despite visits to the clinic every 3 months the amount of protein in her urine was the same. This was in part because her weight was the same too and because she wasn’t taking her ACE inhibitor every day as prescribed.
“What’s going on, Miss Garcia?” I asked. Maybe she was having trouble remembering to take it or was having a dry cough, a common side effect of ACE inhibitors.
“I don’t know,” she giggled. “Sometimes I think the medicine kinda makes me a little tired.” She giggled again.
She giggled like a little girl, not like the young woman she was. And my patience had worn thin for a giggly little girl who couldn’t give me a legitimate reason for not taking care of herself.
“OK, I’m gonna need you to put on your big girl panties and do what you know you need to do to take care of your kidneys,” I lectured and sent her on her way with a prescription for an ARB, an Angiotensin II Receptor Blocker, as a replacement for the ACE that would work similarly and hopefully would not make her “kinda tired sometimes.”
Two weeks later, I got an email from her primary care doctor with a gentle reminder that we all needed to be more diligent in our ensuring our female patients of childbearing age are using effective birth control when we prescribe ACE inhibitors and ARBs. It is well-known that ACEs and ARBs can cause birth defects. Apparently Miss Garcia told her primary care doctor that she was only sometimes taking her medicine because her period was late.
My heart dropped.
I could try to tell myself it didn’t occur to me to counsel Miss Garcia about birth control at every visit as I did with every other woman of childbearing age I’d cared for when prescribing ACEs and ARBs because she came to me already on an ACE or even because of her childlike demeanor. But the truth is, it hadn’t occurred to me that she was sexually active because she was morbidly obese, built like a Fuji apple with limbs.
I’ve long argued that Medicine is not immune to biases because all humans have biases, both conscious and unconscious. Biases that can limit our thinking. Biases that can bring harm to our patients. Biases that we need check ourselves for when we find ourselves doing something different from “standard care.” I had failed to take my own advice.
And now all I can hope is that I’ll do better next time. And that Miss Garcia’s baby will be alright.