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Answer 2
  1. Thrombotic microangiopathy. A renal biopsy is necessary in cases in which clinical features overlap. In this case, given the marked hypertension with clinical manifestations of antiphospholipid-antibody syndrome (APS)—multiple miscarriages, thrombocytopenia, and possibly Libman-Sacks endocarditis— and with the urinary sediment showing no erythrocyte casts, the most likely diagnosis is renal disease due to APS. In APS, pathologic examination can show thrombosis of the glomerular arterioles and capillaries. Unlike lupus nephritis, the lesions are noninflammatory. Mesangial deposition seen only on electron microscopy is associated with class I nephritis. At this level, clinical symptoms are generally absent. Diffuse and segmental glomerulonephritides are commonly associated with erythrocyte casts. IgA deposits are seen in IgA nephropathy and Henoch-Schönlein vasculitis. Patients with renal IgA deposits commonly have gross hematuria.

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