Case (62)

[Diagnostic]

48 yrs old women present to your office complaining of persistent swelling of her feet and ankles, so much so that she cannot put her shoes. she first noted mild ankle swelling about 2-3 months ago and borrowed few diuretic pills from a friend, which seems to help, but now she has run out. she also reports that has gained 20-25 bounds of the last few months, despite regular exercise and trying to adhere health diet.  her past medical hx is significant for type 2 diabetes, for which she takes sulphonyurea she buys in Mexico. she neither sees a doctor regularly nor monitoring her blood glucose at home.  She denies dysurea , urinary frequency, or urgency, but does report that her urine has appeared foamed. She had no fevers, joint pain, skin rash, or GI symptoms
Her physical examination is significant for mild per orbital edema, and multiple had exudates, and dot hemorrhages on fundescopy examination, and pitting edema for her hands, feet, and legs.
Her chest is clear, her heart is regular without heart murmurs and her abdominal exam is benign. She has diminished sensation to light touch in her feet and legs to mid- calf.
Urine dipstick obtained in the office shows ++ glucose, +++protein, and –ve leukocytes strains, niters, and blood.

What is the most likely diagnosis?
What is the best intervention to slow disease progression?

[Kassim]

Thanks for this interesting case.
The answer is straight forward, but let me analyse so that others can benefit.

A diabetic women, with Anasarca, neuropathy, retinopathy and whatever is causing the anasarca.
What is and what Causes of anasarca: 

This condition is always associated with the retention of sodium and occurs when more than 3 litres of interstitial fluid collects.
The extra fluid can lead to a rapid increase in weight over a short period of time (days to weeks).

The principle site of collection of fluid varies with respect to the underlying pathology. Periorbital oedema is seen more often in renal failure (our pt had periorbital oedema), so our pt she has Renal Failure

 ascites (abdominal exam is benign )occurs in cirrhosis, less likely to be cirrhotic

  pulmonary (Her chest is clear ) less likely to be Pulmonary Oedema and  cardiac failure.
The causes of generalised oedema are, in general, the result of either an increased venous pressure (eg right heart failure), or a decrease in intravascular oncotic pressure

  Causes of generalized oedema include:
•   increased venous pressure e.g. right cardiac failure
•   reduced intravascular oncotic pressure e.g. hypoalbuminaemia
o   liver cirrhosis
o   nephrotic syndrome
•   renal failure - this may result in generalised oedema
o   impaired sodium excretion
Other possible causes include:
•   pregnancy or other pelvic mass
•   hypothyroidism
•   angioneurotic oedema
•   steroid therapy
•   starvation: particularly on refeeding
since our patient cardiac examination was not detailed and hint of CCF in this case, this excludes CCF.
No symptoms of Cirrhosis given in this case.
The Anasarca, neuropathy, retinopathy, patient could also have Diabetic Nephropathy.
Diabetic Nephropathy Leading to loss of protein (proteinurea)and retention of Salt (Na)  leading to  the  Anasarca.

What is the most likely diagnosis?

Diabetic Nephropathy.

Before jumping to the management part, first i have to make sure my Diagnosis is correct.

Serum Creatinine, this will also determine whether she has to continue her Metformin, because if Cre is high and she continuous Metformin she could develop Lactic Acidosis.
Urea.
Abdominal  U/S  to exclude liver cirrhosis, GFR to assess the stage of the Renal Failure.
Stage 1
Slightly diminished function; Kidney damage with normal or relatively high GFR (≥90 mL/min/1.73 m2).
Stage 2
Mild reduction in GFR (60-89 mL/min/1.73 m2) with kidney damage.
Stage 3
Moderate reduction in GFR (30-59 mL/min/1.73 m2).
Stage 4
Severe reduction in GFR (15-29 mL/min/1.73 m2)
Stage 5
Established kidney failure (GFR <15 mL/min/1.73 m2


 What is the best intervention to slow disease progression?The outcome of the Lab and the U/S will determine how we manage this patient.
Stage 1-3 ACE inhibitors.
Stage 4-5, dialysis, Preparation for renal replacement therapy, and stop Metformin.
Hope this the right answer.

[Diagnostic]

Thanks Dr Kassim for the detailed answer and welcome back, long time no see.