Lessons from treatment resistant hyperlipidaemia.

A 68-year-old woman was referred to Lipid Clinic with sudden deterioration of previously well-controlled primary hyperlipidaemia. Investigations revealed nephrotic range proteinuria, leading to urgent renal biopsy and a diagnosis of amyloidosis. Chemotherapy was successful in stabilising renal function, reducing proteinuria and eliminating serum paraprotein. The resistant hyperlipidaemia subsequently resolved. Whilst hyperlipidaemia is pathognomonic of nephrotic syndrome, it is rarely the first characteristic identified by clinicians, often preceded by the identification of oedema or proteinuria. This case is an unusual example of a nephrotic syndrome presenting to Lipid Clinic as a resistant primary hyperlipidaemia, and highlights the importance of considering superimposed secondary causes of hyperlipidaemia in treatment resistant cases.