CPC 5 Peripheral oedema

Question 1

List differentials for the following patient:
Mr KA

 Swelling of legs
 Frusemide had no effect. 
 No PMH, on multivits, mother had DM
 Examination: HR 80. BP 140/80, JVP not seen. Small right pleural effusion 
in chest.

Answer 1

Congestive cardiac failure, liver failure, nephrotic syndrome,
chronic kidney disease stage IV.

Question 2

List groups in which to consider underlying causes of peripheral oedema

Answer 2

Increased hydrostatic pressure

Decreased oncotic pressure

Question 3

Causes of increased hydrostatic pressure leading to peripheral oedema

Answer 3

Increased intravascular pressure.

Increased lymphatic hydrostatic pressure

Question 4

Intravascular causes of increased hydrostatic pressure

Answer 4

Heart failure
Volume overload
Venous obstruction

Question 5

Types of heart failure

Answer 5

HF with reduced ejection fraction

HF with preserved ejection fraction.

Question 6

Lymphatic causes of increased hydrostatic pressure leading to peripheral oedema

Answer 6

Obstruction of lymphatics:
Malignancy
Previous radiotherapy
Filariasis

Question 7

Causes of decreased oncotic pressure leading to peripheral oedema

Answer 7

Excess protein loss (nephrotic syndrome)
Inadequate protein synthesis (liver failure)
Inadequate protein absorption (bowel, pancreas)
Inadequate protein intake.

Question 8

Common causes of bilateral leg oedema

Answer 8

Increased hydrostatic pressure: volume overload, RHF, CCF.

Decreased oncotic pressure: chronic liver failure, nephrotic syndrome.

Question 9

The ABC of glomerulonephropathies

Answer 9

A = aetiology (primary or secondary)
B = biopsy
C = clinical presentation

Question 10

Primary glomerulonephropathies

Answer 10

Minimal change, membranous GN, FSGS and MCGN

Question 11

Causes of membranous GN

Answer 11

Idiopathic in 2/3 cases, but can be associated, with drugs, SLE, HepB, HepC malaria and malignancy of a solid organ.
Anti-PLA2RI antibody has also been associated.

Question 12

Causes of secondary glomerulonephritides.

Answer 12

Infection, autoimmune disease, diysgammaglobulinaemias, drugs and malignancy
Diabetes mellitus, amyloidosis, SLE and infection.

Question 13

Purpose of biopsy in glomerulonephritis

Answer 13

 Gives diagnosis.

 Suggests how much damage, and reversibility.

 Directs treatment and prognosis.

Question 14

Clinical presentation of minimal change GN

Answer 14

Proteinuria, normal GFR, normal BP

Question 15

Clinical presentation of membranous GN

Answer 15

Proteinuria, mild renal impairment and mild hypertension.

Question 16

Clinical presentation of FSGS

Answer 16

Proteinuria, mild renal impairment and mild hypertension.

Question 17

Clinical presentation of diffuse proliferative GN

Answer 17

Mild to severe proteinuria, renal impairment and

hypertension.

Question 18

First presentation of nephrotic syndrome

Answer 18

Frothy urine and lethargy.

Question 19

Nephrotic syndrome triad

Answer 19

Oedema, hypoalbuminaemia, proteinuria.

Question 20

Protein results for nephrotic syndrome

Answer 20

Either 24h urine protein of
>3.5g, or ACR of >220 (normal is 3.0 mg/mmol) or PCR of >300
(normal

Question 21

What are the results of loss of protein in nephrotic syndrome?

Answer 21

Frothy urine, clotting abnormalities, immunocompromised.

Question 22

Severity and results of hypoalbuminaemia in nephrotic syndrome

Answer 22

Less than 30 g/l, or less than 20 g/l if severe.

Leads to hypercholestraemia, hypercoagulable, reduced oncotic pressure leading to oedema.

Question 23

Common causes of presentation of nephrotic syndrome

Answer 23

Minimal change GN, FSGS and membranous GN (most common).

Question 24

Complications of nephrotic syndrome

Answer 24

o Thromboembolism
o Infection
o Hypercholestraemia
o Hypovolaemia.

Question 25

Nephritic syndrome triad

Answer 25

Haematuria, renal impairment and hypertension.

Question 26

Investigations into glomerulonephropathies

Answer 26

CRP/ESR
Autoimmune serology
Serum immunoglobulins
Hepatitis serology

Question 27

General treatment for nephrotic syndromes

Answer 27

 Diuretics
 Fluid restrict
 ACEI/ARB
 Aspirin
 Warfarinise if albumin

Question 28

Treatments for membranous GN

Answer 28

Chlorambucil and steroids (ponticelli regimen)
 Cyclophosphamide and steroids
 Tacrolimus.
 Rituximab (aCD20) and Belimumab (aBAFF).

Question 29

In heart failure, what biomarker is raised?

Answer 29

BNP and NTproBNP are secreted in response to ventricular stretch. Stimulate sodium and water elimination by the kidney and are elevated in heart failure. Negative BNP is a rule out for heart failure in non-treated patients.

Question 30

Causes of HF-REF

Answer 30

 Myocardial infarction

 Dilated cardiac myopathy (genetic, viral, autoimmune, alcohol, drugs, peripartum)

 Acute myocarditis

 Valvular disease

 Arrhythmias

Question 31

Causes of HF-PEF

Answer 31

 Left ventricular hypertrophy (secondary to hypertension)

 Genetic

 Infiltrative disorders inc amyloidosis and sarcoidosis.

 Valvular heart disease.

Question 32

Causes of high output heart failure

Answer 32

Anaemia, pregnancy, hyperthyroidis, Paget’s disease, AV malformation.