The urine shows microscopic hematuria and red cell casts

A 27-year old male presents with complaints of general malaise, fever, and vague joint and muscle pain that have been going on for about 12 weeks. Last 4 days, he has had 2 episodes of hemoptysis and coughing spells. He claims that he has never had an appetite for food and was never able to participate in sports because he was always short of breath. He has been to many healthcare providers but no cause was ever found. On physical, his vitals are BP 160/95, P 110, RR 26 and T 99.8 F. Auscultation reveals crackles bilaterally. He has mild pedal edema. Blood work reveals elevated BUN and creatinine levels with a mild leucocytosis. The urine shows microscopic hematuria and red cell casts. The patient is admitted and referred to a nephrologist who performs a kidney biopsy. The immunofluorescence stain is shown in the image. Five days later, the patient develops massive hemoptysis and his blood pressure is 90/55. The patient’s arterial blood gas is pH 7.21, PO2 87, PCO2 50 and bicarbonate 18.3. What is your next step in the management of this patient?


A. Hemodialysis
B. Plasmapheresis
C. Immediate Thoracotomy
D. Angiographic embolization