10 - Renal Case Study Flashcards
(35 cards)
Describe the patient presentation
- 32 y/o African-American female seen for bilateral ankle and leg swelling of one month duration
- Concerned about a 10 lb weight gain
Describe what you find in the review of systems
- Nocturia (urinating at night)
- “Foamy” urine (bubbly)
- Denies cold intolerance
- Normal menstrual cycle w/o edema
- 2 uneventful full-term pregnancies
Describe the medical history of this patient
- Excellent health
- No medications
- No allergies
- Family history non-contributory
Describe the social history of this patient
- Denies tobacco, alcohol, illicit drugs
- Normal appetite with no change in diet
- Regular exercise without fatigue or dyspnea
Describe the vitals of this patient
- BP: 110/70
- Pulse: 80
- Respirations: 12
- Temp: 36.6°C
Normal
Describe the physical exam
- Cardiopulmonary exam: normal
- Abdominal exam: normal
- Neurovascular exam: normal
- Musculoskeletal exam: normal
Describe the dermatological exam
- No jaundice or pallor
- 2+ pitting edema of anterior tibial crest
- Whitish lines on toenails and fingernails parallel to the lunula
What does pitting edema suggest to you?
Pitting edema
- No excess of pitting in the soft tissue
Non-pitting
- Excess of protein in the soft tissue
What does the H&P suggest?
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)
What are the three major etiologies of peripheral edema?
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
How do the main 3 cause edema?
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
In CHF, what would you see?
FINISH
In CHF, edema also caused by increased capillovenous pressure
In cirrhosis, what would you see?
FINISH
- In cirrhosis, edema caused by **hypoalbuminemia, **portal hypertension, intrahepatic lymphatic obstruction, and inability to destroy antidiuretic hormone and aldosterone contribute to ascites
So, do you think it is CHF?
No…
- Cardio exam is normal
- No history of heart disease
- Able to exercise with no impairment
- No family history
Is it cirrhosis?
No…
- No jaundice
- No abdominal mass
- No liver enlargement
- Denies alcohol and other drug use
- Not on any medications that cause liver problems
Is it kidney disease?
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
Is it hypothyroidism?
No…
- No cold tolerance
- Normal bowel habits
Is it cyclic edema?
No…
- No edema during menstruation
Is it pregnancy?
No…
- Husband had his “tubes tied” after birth of second child
What do you do next?
- 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)
List the results
- 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
Describe the urinalysis
- 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
Describe the microscopic urinalysis
- 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
Describe the proteinuriea
- 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”
