11/7/17 Intern Morning Report – Lower Extremity Edema, Periorbital Swelling, Weight Gain, Nephrotic Syndrome, Diabetic Nephropathy

CC: Lower extremity swelling for 2 months

HPI: 32 year-old male with no known past medical history who presents with a chief complaint of lower extremity swelling for 2 months. Patient reports that he noticed swelling in his feet approximately 2 months prior to admission that has gradually worsened in severity. He now reports swelling extending to mid thighs that interferes with ability to ambulate comfortably, prompting him to present for evaluation. The swelling is not painful and without overlying skin discoloration and is symmetric bilaterally; he also states that his swelling is not firm but pits with digital pressure. He notes mild periorbital swelling over the past 3 weeks though he reports no visual disturbances.  On exam, patient has periorbital edema and pitting lower extremity edema to mid thigh but otherwise no other signficant findings.  Labs are significant for renal injury, non-gap acidosis, hyperkalemia, normocytic anemia, and UA>300 protein.  The urine protein/creatinine ratio is 13.84, high above the cut off for nephrotic range proteinuria.  Urine anion gap is positive. For work up of nephrotic syndrome, tests of ANA, SPEP/UPEP, Hepatitis panel, HIV, RPR, C3/C4, and HgbA1c were sent.  The only pertinent finding was a HgbA1c of 10.1.  A renal biopsy was pursued after ultrasound showed kidneys to be around 12cm in length with no other specific findings.  Biopsy demonstrated patient to have Kimmelstiel Wilson nodules which is consistent with Diabetic Nephropathy.


Morning Report Pearls:

Once you have nephrotic range proteinuria, remember the types of nephrotic syndromes. This will help organize how to evaluate for underlying etiologies. Some of these syndromes can be idiopathic but most have secondary causes.

  1. Membranous – Associated with Hepatitis B, Hepatitis C, Malaria, Syphilis, SLE, Medications, Malignancies (solid tumor and lymphoma), RA, and Sjogren’s
  2. Minimal Change – Associated with medications like NSAIDs, Malignancies (Hodgkin’s Lymphoma)
  3. FSGS – HIV, Obesity, Reflux Nephropathy, Sickle Cell, HTN, DM
  4. Amyloidosis
  5. Multiple Myeloma (Membranoproliferative possible finding)
  6. Diabetic
  7. IgA Nephropathy

Some basic screenings should be done based off this information: HIV, HgbA1c, ANA, C3/C4, Hepatitis B/C, SPEP/UPEP with Light chains

 

Be on the look out for complications related to Nephrotic Syndrome secondary to loss of albumin (drop in oncotic pressure) and other proteins:

  • Hyperlipidemia due to increase hepatic production of apolipoproteins due to loss of oncotic pressure and decrease lipoprotein lipase
  • Hypercoaguablility due to loss of Protein C, Antithrombin II and increase production of coagulation factors from decrease oncotic pressure. Note that renal vein thrombosis is most common in Membranous Nephropathy
  • Higher risk of infection due to loss of Immunoglobulins
  • Due to loss of carrier proteins some patients can become Vitamin D deficiency, Thyroid hormone deficient, Iron deficient

This patient had a non gap acidosis for which the differential is narrow:

  1. GI loss
  2. Renal Acidosis – RTA versus CKD
  3. Drug Induced

Given the hyperkalemia in the setting of lack of oliguria or insults with CKD, it was thought that patient had Type IV RTA. Here is a breakdown of the RTAs:

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