Edema (Case 13)

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Chapter 20
Edema (Case 13)

Ellena Linden MD and Dennis Finkielstein MD

Case: A 55-year-old man presents with complaints of increasing lower extremity swelling over the past several months. He otherwise feels well and has no other complaints. He does not have chest pain but does become short of breath when climbing stairs; he attributes this to lack of exercise and deconditioning. He has no dyspnea at rest. His past medical history is unremarkable. He does not take any medications on a regular basis. This man does not smoke or use alcohol currently, although he admits to having been an alcoholic in the past. He does not use recreational drugs. On physical exam he appears well. Blood pressure is 110/60 mm Hg, and heart rate is 80 beats per minute. His weight is 80 kg, up from 72 kg a few months ago. Cardiovascular, pulmonary, and abdominal exams are unremarkable. There is significant pitting edema of both lower extremities.

Differential Diagnosis

image

 

Speaking Intelligently

Nephrotic syndrome is a constellation of findings, which includes nephrotic-range proteinuria (defined as urinary protein excretion of greater than 3.5 g in a 24-hour period), edema, hypoalbuminemia, and dyslipidemia. Proteinuria in nephrotic syndrome might be the only sign of renal disease; these patients often have normal creatinine levels, lack of hematuria, and normal-appearing kidneys on radiologic imaging. Patients with nephrotic syndrome are predisposed to thromboembolic disease.

PATIENT CARE

Clinical Thinking

• Attempt to identify the cause.

• Determine whether nephrotic syndrome is part of a systemic disease (such as diabetes mellitus or SLE) or an isolated renal disease.

• Look for evidence of systemic disease; if one is not found, it is likely that the nephrotic syndrome is due to a purely renal disease.

• Establishing that nephrotic syndrome represents a purely renal disease is the beginning of the next level of investigation as to the exact cause; this step usually requires a percutaneous renal biopsy.

History

Cardiac dysfunction: Does the patient have orthopnea or paroxysmal nocturnal dyspnea?

Thyroid disease: Is the patient fatigued? Is there constipation? Cold intolerance? Weight gain?

Liver disease: Is there history of hepatitis, cirrhosis, or jaundice?

Kidney disease: Is there hematuria?

• Certain medications (most notably calcium channel blockers) can cause lower extremity edema; therefore, a medication history should also be obtained.

Physical Examination

• Is the edema localized or generalized, pitting or nonpitting, bilateral or unilateral?

Cardiac function: Is there jugular venous distension? Are there murmurs? Is there pulmonary edema?

Liver function: Is there ascites? Are the liver and spleen palpable? Is the patient jaundiced? Are there any signs of cirrhosis and portal hypertension (caput medusae, telangiectasia, gynecomastia)?

Venous obstruction: Is the edema unilateral, increasing the suspicion of deep venous thrombosis?

Thyroid disease: Is there unexplained weight gain? Alopecia? Bradycardia? Generalized slowing such as slow movement and speech?

Renal function: Unfortunately, there are often no specific physical findings of kidney disease. However, signs of systemic diseases involving the kidneys can often be identified. For example, a patient with renal involvement from lupus will have systemic signs of lupus such as rash or arthritis.

Tests for Consideration

Liver function tests to assess for cirrhosis

$12

Thyroid-stimulating hormone (TSH) levels, especially if the edema is nonpitting

$24

Urinalysis to look for proteinuria and microscopic hematuria

$4

Serum creatinine to look for renal disease

$12

• Quantify the amount of proteinuria by obtaining either a 24-hour urine collection or a spot urine protein-to-creatinine ratio.

$12

• Check lipid panel and serum albumin.

$19, $7

• Once the diagnosis of nephrotic syndrome is established, the next step is to determine the cause. There are many diseases that can cause nephrotic syndrome. We start with looking for systemic causes:

 

Does the patient have diabetes? Check fasting glucose.

$7

Are there any signs of lupus? Check antinuclear antibodies (ANA), and complements C3 and C4.

$16, $34

Are there any signs of amyloid or multiple myeloma? Check serum and urine protein electrophoresis and immunofixation.

$40

Does the patient have HIV? Check HIV antibody.

$13

Does the patient have hepatitis B or C? Check the respective antigens and antibodies.

$54

 

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