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[Blocked from Release] 0828201704

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Topic updated on 08/28/17 2:35pm

Snapshot
  • A 67-year-old man with a history of type 2 diabetes and hypertension presents with worsening pedal edema. His diabetes has been poorly controlled and his last HbA1C was measured at 9.7 about 3 months ago. He reports no other symptoms. Physical exam reveals bilateral 2+ pitting edema to the knees bilaterally, and fundoscopy reveals cotton wool spots. A urinalysis shows 3+ protein, and serum albumin is 2.5. He is prescribed an ACE-inhibitor by his physician. (Diabetic Nephropathy) 

 

Introduction
  • Secondary nephrotic syndrome is a multisystem disease 
  • Primary nephrotic syndrome refers to disease limited to kidney
Presentation
  • Hypoalbuminemia (serum albumin of <3.0 g/dl)
  • Proteinuria > 3.5 g/day
  • Generalized edema (anasarca)
    • caused by loss of albumin / decreased oncotic pressure
  • Hyperlipidemia with lipiduria
    • low albumin stimulates liver to produce cholesterol
  • Hypercoaguable state 
 
Differential
 
Nephrotic Syndrome
Nephritic Syndrome
Chronic Disease
Proteinuria
+ + +
+ / -
+ / -
Hematuria
+ / -
+ + +
+ / -
Cells
+ / -
+ RBCs / + WBCs
+ / -
Casts
Fatty Casts
RBC and granular casts
Waxy/pigmented/granular casts
Lipids
Free fat droplets
Oval fat bodies
   

 

Evaluation
  • Labs show
    • hypoalbuminemia (serum albumin of <3.0 g/dL) 
    • proteinuria > 3.5 g/day
    • hyperlipidemia with lipiduria
    • low albumin stimulates liver to produce cholesterol
  • Definitive diagnosis made by renal biopsy


Generalized Treatment
  • Management of primary disease process causing nephrotic syndrome
     
  • Protein restriction
  • Salt restriction
  • Diuretic therapy for edema
  • HMG-CoA reductase inhibitor for hyperlipidemia
Diabetic Glomerulonephropathies
  • Most common cause of end stage renal disease in USA
  • Early manifestation is microalbuminuria
  • Biopsy shows pathognomnic Kimmelstiel-Wilson nodules
  • Treatment
    • can slow progression with
      • ace inhibitors
      • strict glycemic and hypertension control
    • transplant is only treatment after disease has progressed
HIV Glomerulonephropathies
  • Usually seen in HIV acquired through IV drug use
  • Presents with focal segmental glomerulonephritis
  • Treat HIV
Lupus Glomerulonephritis
  • Type I
    • no renal involvement
  • Type II
    • mesangial disease with focal segmental glomerular pattern
  • Type III
    • focal proliferative disease
    • treat with aggressive prednisone +/- cyclophosphamide
  • Type IV
    • most severe form
    • diffuse proliferative disease
    • presents as combination of nephritic and nephrotic disease
    • classic wire loop abnormality (image above)
    • treat with prednisone, cyclophosphamide, transplant
  • Type V
    • membranous disease
    • indistinguishable from other primary membraneous glomerulonephropathies
    • Treatment: consider prednisone
 

 



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Qbank (1 Questions)

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(M2.RL.4754) A 57-year-old immigrant from Nigeria presents to the emergency department for sudden, severe pain and swelling in her lower extremity. She was at a rehabilitation hospital when her symptoms became apparent. The patient has a past medical history of obesity, diabetes, bipolar disorder, and tonic-clonic seizures. Her current medications include metformin, insulin, lisinopril, and valproic acid. The patient is a prominent IV drug and alcohol user who has presented to the ED many times for intoxication. On physical exam you note anasarca and asymmetric lower extremity swelling. Based on the results of a doppler ultrasound of her swollen lower extremity, heparin is started. The patient is then transferred to the general medicine floor for continued management. Laboratory studies are shown below.

Serum:
Na+: 137 mEq/L
K+: 5.5 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/L
Urea nitrogen: 22 mg/dL
Ca2+: 5.7 mg/dL
Creatinine: 1.7 mg/dL
Glucose: 70 mg/dL

What is the most likely diagnosis?
Topic Review Topic

1. Factor V Leiden
2. Antithrombin III deficiency
3. Prothrombin gene mutation
4. Liver failure
5. Nephrotic syndrome

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