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GI and Renal Exam 1 > 10 - Renal Case Study > Flashcards

10 - Renal Case Study Flashcards

1
Q

Describe the patient presentation

A
  • 32 y/o African-American female seen for bilateral ankle and leg swelling of one month duration
  • Concerned about a 10 lb weight gain
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2
Q

Describe what you find in the review of systems

A
  • Nocturia (urinating at night)
  • “Foamy” urine (bubbly)
  • Denies cold intolerance
  • Normal menstrual cycle w/o edema
  • 2 uneventful full-term pregnancies
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3
Q

Describe the medical history of this patient

A
  • Excellent health
  • No medications
  • No allergies
  • Family history non-contributory
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4
Q

Describe the social history of this patient

A
  • Denies tobacco, alcohol, illicit drugs
  • Normal appetite with no change in diet
  • Regular exercise without fatigue or dyspnea
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5
Q

Describe the vitals of this patient

A
  • BP: 110/70
  • Pulse: 80
  • Respirations: 12
  • Temp: 36.6°C

Normal

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6
Q

Describe the physical exam

A
  • Cardiopulmonary exam: normal
  • Abdominal exam: normal
  • Neurovascular exam: normal
  • Musculoskeletal exam: normal
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7
Q

Describe the dermatological exam

A
  • No jaundice or pallor
  • 2+ pitting edema of anterior tibial crest
  • Whitish lines on toenails and fingernails parallel to the lunula
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8
Q

What does pitting edema suggest to you?

A

Pitting edema
- No excess of pitting in the soft tissue

Non-pitting
- Excess of protein in the soft tissue

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9
Q

What does the H&P suggest?

A

You are evaluating swelling… So, thinking of the system you are now in, what could cause this?

  • CHF (backup of fluid, increased pressure driving fluid out of vessels)
  • Kidney failure (glomeruli failure)
  • Liver failure (Nothing palpable on abdomen and no jaundice, but if it had liver failure possible - cirrhosis leading to edema from decreased protein production)
  • NO pallor (whitish) indicates that the patient probably does NOT have anemia
  • Anemia would be due to kidney failure (produces erythropoetin)
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10
Q

What are the three major etiologies of peripheral edema?

A

Three major

  • CHF
  • Cirrhosis of liver
  • Nephrotic syndreme

Others

  • Hypothyroidism
  • Idiopathic cyclic edema (edema during menstruation)
  • Pregnancy

Together, these are the main 6 systemic, metabolic causes of peripheral edema

The MOST common cause of peripheral edema is venous insufficiency, but that is localized, not systemic

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11
Q

How do the main 3 cause edema?

A

Mechanism of edema

  • All three lead to DECREASED RENAL PERFUSION, leading to activation of renin-angiotensin-aldosterone system
  • This leads to increased sodium and water retention to maintain effective blood volume

Direct

  • Renal = direct damage to glomeruli
  • Liver = cirrhosis leads to increased production of vasodilators which increase splanchnic circulation and “steals” blood flow from the kidney
  • Cardiac = increased cardiac output
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12
Q

In CHF, what would you see?

FINISH

A

In CHF, edema also caused by increased capillovenous pressure

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13
Q

In cirrhosis, what would you see?

FINISH

A
  • In cirrhosis, edema caused by **hypoalbuminemia, **portal hypertension, intrahepatic lymphatic obstruction, and inability to destroy antidiuretic hormone and aldosterone contribute to ascites
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14
Q

So, do you think it is CHF?

A

No…

  • Cardio exam is normal
  • No history of heart disease
  • Able to exercise with no impairment
  • No family history
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15
Q

Is it cirrhosis?

A

No…

  • No jaundice
  • No abdominal mass
  • No liver enlargement
  • Denies alcohol and other drug use
  • Not on any medications that cause liver problems
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16
Q

Is it kidney disease?

A

Yes…

  • Nocturia and “foamy urine” which suggests proteinuria ***
  • Paired white lines “Muehrcke’s lines” are seen in hypoalbuminemia ***

These suggest that we are spilling protein or are not making enough protein… or both

Hypoalbuminemia could be caused by spillage into urine

17
Q

Is it hypothyroidism?

A

No…

  • No cold tolerance
  • Normal bowel habits
18
Q

Is it cyclic edema?

A

No…

- No edema during menstruation

19
Q

Is it pregnancy?

A

No…

- Husband had his “tubes tied” after birth of second child

20
Q

What do you do next?

A
  • Creatinine (kidney function test)
  • Urinalysis
  • Urine culture
  • AST, ALT, total protein (liver function tests - total protein is albumin and globulin)
  • Cholesterol (low lipoprotein lipase so high cholsesterol in liver problem)
  • BMP (basic metabolic panel)
  • TSH (for thyroid function)
  • CBC (hemoglobin for anemia)
  • 2 hour PP glucose, ANA, serum complement *** (not the ones you aren’t expected to know, but they will be relevant for this patient)
21
Q

List the results

A
  • CBC normal
  • No advanced renal insufficiency
  • This is because erythropoetin is not elevated (look at slide)
  • NOTE - liver disease can cause iron deficiency anemia due to decreased production of transferrin
22
Q

Describe the urinalysis

A
  • pH 6.0
  • Trace of glucose* (170+ BS?)
  • Urobilinogen and bilirubin-negative
  • Protein 4+*
  • Microscopic

If you are getting a lot of protein loss, it can bring glucose with it without being diabetic

23
Q

Describe the microscopic urinalysis

A
  • One WBC and RBC/hpf (high power field)
  • Two to four hyaline casts with fatty inclusions and one oval fat body/hpf* (“fat in urine”)
  • Urine culture negative

All is normal except fat in urine

24
Q

Describe the proteinuriea

A
  • Protein of 4+ suggests nephrotic syndrome
  • Proteinuria of renal-based disorders is PRIMARILY composed of albumin
  • This is because it is the smallest of the major proteins and, therefore, is the first to “leak out”
25
Q

What does the microscopic urinalysis mean?

A

Few WBC and RBC suggest we are not dealing with a typical glomerulonephropathy

Casts with fatty inclusions and fat bodies point towards nephrotic syndrome

  • In the syndrome, hepatic synthesis of lipoproteins is increased
  • Secondary to hypoalbuminemia and decreased amounts of lipoprotein lipase
26
Q

What does serum protein electrophoresis show?

A
  • Serum protein electrophoresis shows decreased albumin
  • Total proteins are 5.1g/dL (albumin 2.1 g and globulin 3.0 g)
  • Serum cholesterol is 390 mg/dL
27
Q

What is the serum creatinine?

A

Serum creatinine is 0.9 mg/dL

This is normal because she has not been experiencing symptoms for long

28
Q

Describe the lab work for nephrotic syndrome

A
  • 2 hPPG is 98mg/dL (for diabetes - normal)
  • ANA is absent (for lupus - normal)
  • Serum complement is normal (distinguish between the types of nephrotic syndromes)

These three tests were ordered to seek a cause for the nephrotic syndrome

29
Q

Describe complement levels in nephrotic syndrome

A

Disorders in which C3 is decreased but C4 is not include MPGN and post-infectious glomerulonephritis; disorders in which BOTH C3 and C4 are decreased include lupus nephritis and cryoglobulinemia.

30
Q

What is the sequence of events seen in nephrotic syndrome

A
  • Glomerular defect
  • Massive proteinuria
  • Hypoalbuminemia
  • Edema
  • Decreased renal blood flow
  • Renal retention of salt and water
  • More edema
31
Q

What do we know now?

A
  • Complement is normal
  • No matter what is the cause of the nephrotic syndrome, glomerular injury is the common denominator
  • List of causes is massive
32
Q

What do we do now?

A

Renal biopsy

33
Q

What does histological diagnosis include?

A
  • Mesangial proliferative glomerulonephritis
  • Focal and segmental glomerulosclerosis
  • Membranous glomerulopathy
  • Membranoproliferative glomerulonephritis

Don’t need to know this for exam

34
Q

What is the final diagnosis for this patient?

A

Final diagnosis is membranous glomerulopathy, an immune complex form of glomerulonephritis

35
Q

What is the list of differentials that are systemic causes of peripheral edema

KNOW THIS

A

C CHIP N’ DALE

  • CHF
  • Cirrhosis
  • Hypothyroidism
  • Intermittent cyclical edema
  • Pregnancy
  • Nephrotic syndrome
  • Decreased renal perfusion
  • Alcohol
  • Liver
  • Edema

GI and Renal Exam 1 (16 decks)

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